LEGAL RELATIONSHIP BETWEEN EMERGENCY ROOM AND PHYSICIANS
I am aware that my doctor may have an ownership interest in Ascent Emergency Medical Center and that I have a right to seek medical treatment elsewhere. A list of physician owners may be obtained upon request by the patient or legal guardian.
ASSIGMENT OF INSURANCE BENEFITS
I assign Ascent Emergency Medical Center and Drew Emergency Physicians, PLLC. all right, title, and interest in any and all health insurance and/or health plan proceeds/benefits from any plan(s) arising from the provision of any goods and services provided by Ascent Emergency Medical Center and Drew Emergency Physicians, PLLC. and/or physicians/healthcare providers thereof. This assignment is made in accordance with §1204.054, Tex. Ins. Code.
I further assign and transfer to Ascent Emergency Medical Center and Drew Emergency Physicians, PLLC. all rights, title, and interest in any claims against any health insurers, sponsors and/or plan administrators of any of my health benefit plan(s) arising from or pertaining to any wrongful acts and/or omission pertaining to any of said health/benefit plan(s) or health insurance policy(ies) including, but not limited to, claims for a non-payment or underpayment of health provider invoices and claims. I further expressly and knowingly assign all rights under my benefit plan and the Employee Retirement Income Security Act of 1974 to sue my benefit plan for any breach of its fiduciary duty. By executing this assignment of benefits, I am directing the health insurance carrier or other health benefit plan providing my coverage (including, but not limited to, any employers, employer group, or trust sponsored or offered plan), to pay Ascent Emergency Medical Center and Drew Emergency Physicians, PLLC., and any consultant physician services for which may be billed on my behalf.
Ascent Emergency Medical Center, and Drew Emergency Physicians, PLLC. file primary and secondary insurance claims for insured patients. I authorize the facility and/or physicians indicated above to release medical information about me as may be necessary for the completion of my insurance claims for this occasion of service to any insurance carrier or health plan.
FINANCIAL AGREEMENT AND PATIENT GUARANTEE
Ascent Emergency Medical Center is NOT a participating Medicare, Tricare, or Medicaid provider. Medicare, Tricare or Medicaid beneficiaries will be charged in accordance with the facility’s prompt-pay fee schedule. Ascent Emergency Medical Center will not file a claim to Medicare, Tricare or Medicaid. Medicare, Tricare and Medicaid recipients may be personally responsible to Ascent Emergency Medical Center and Drew Emergency
Physicians, PLLC. for payment.
Ascent Emergency Medical Center is an “out-of-network” provider with all insurance and/or health benefit plan. I understand that my out-of-network payment responsibility may be higher than an in-network option. Texas Insurance Law states that if a condition is deemed a medical emergency, insurance will pay in accordance with the plan’s benefits of the services at the “in-network” benefit level, but not all emergency room services are medical emergencies. I understand that my facility bill is inclusive of laboratory and radiology services provided to me during my length of stay. I understand that if a consulting physician is used during the course of treatment rendered to me that I will be duly informed and will be responsible for any charges incurred for such consultation physician services. In accordance with the No Surprise Act requirement the beneficiary or guarantor will not be balanced billed for any amounts which are considered not allowable by your insurance company. The guarantor or beneficiary will only be billed for co-pays, deductibles and co-insurance amounts in accordance with the insurance plan.
I understand that physicians or healthcare providers rendering services to me while at Ascent Emergency Medical Center may bill separately. I understand that physicians or healthcare providers providing services while at Ascent Emergency Medical Center may not be participating providers with the same third-party payers or benefit plans. I understand that I am responsible for paying all providers subject to the terms of my health plan or insurance, if any.
I agree, whether signing as agent or a patient, that in consideration of the services to be rendered, I hereby am responsible for paying facility copayments, deductibles, estimated facility coinsurance amounts, and any balances deemed not to be a covered benefit of the insurance policy. These payments may be due AT TIME OF SERVICE. Monthly statements will be sent to guarantors for account balances. Acceptable means of payments are cash, money order, cashier’s check, credit card, or personal checks. I further understand that during my length of stay if I am evaluated by a physician other than the attending emergency room physician that I may be billed for those physician services.
Unless prior arrangements are made, prompt-pay balances must be paid in full prior to discharge. If the balance due is referred to a collection agency or attorney, I understand that there may be additional fees, interest, and expenses that I will be responsible. Questions regarding your bill may be directed to: Wise Staff Billing at (346) 304-6871.
NON-COVERED SERVICES
If any of the provided services are not covered by my insurance company, or if Ascent Emergency Medical Center or Drew Emergency Physicians, PLLC. is not able to verify eligibility, I am responsible for all charges incurred for services rendered.