Thank you for choosing Deaconess. Our goal is to provide you with quality medical services. Your clear understanding of our financial policy is important to our professional relationship. Please understand that payment of your bill is vital to our ability to continue to provide medical care within the community. We accept Cash, Check, Visa, MasterCard and Discover.
In consideration of a Deaconess Health System, Inc. affiliate, including but not limited to Deaconess Hospital, Inc., Deaconess Clinic, Inc., Methodist Health, Inc. d/b/a Deaconess Henderson Hospital and d/b/a Deaconess Union County Hospital, and Gibson General Hospital, Inc. d/b/a Deaconess Gibson Hospital (collectively “Deaconess”), rendering services for the above named patient, I/we, the undersigned, and each of us, agree to be jointly and severally responsible for payment for these services and any other account that the patient had at any time in the past, at the present, or may have in the future with Deaconess. I/we agree that the charges for which I/we are responsible will be calculated according to Deaconess’s Chargemaster and I/we agree to pay those Chargemaster rates. All accounts are due and payable at the time of the patient’s discharge. Any credit will be applied to outstanding balances prior to being refunded. Please contact the Deaconess Financial Counseling Services at 812-450-6815 if you need assistance. Past due patient accounts that do not have agreed upon financial arrangements with Deaconess will be submitted to a collection agency or attorney for collection. I/we agree that I/we will pay all attorney fees and court costs incurred by Deaconess in the collection of all sums due Deaconess.
If I/we provide Deaconess or its agents with our cell phone number, I/we authorize Deaconess or it agents to contact us at that cell phone number by calling or text messages, which could result in charges to me. I/we authorize Deaconess to contact us on our cell phone number by using pre-recorded artificial voice messages and/or use of an automatic dialing device. I/we understand that any e-mail address I/we provide is our personal e-mail address and I/we authorize Deaconess or its agents to contact us via that e-mail address.
WORKER’S COMP / LIABILITY / AUTO ACCIDENT
If the reason for your visit is related to a workers comp claim, liability claim, or auto accident, you are responsible for providing Deaconess with complete billing information, including police report, claim number, etc. as appropriate, within seven (7) business days. You should be aware that if you do not provide this information or these claims are denied, the balances then become the patient’s responsibility.
If the patient has active insurance coverage, we will bill the patient’s insurance company. It is the patient’s responsibility to understand his/her insurance coverage. Payment of deductibles, non-covered services and co-payments are your responsibility.
ASSIGNMENT OF INSURANCE BENEFITS
I/we assign insurance payments to be made directly to Deaconess for services rendered. I/we have read, understand and agree to the terms listed above.
NOTICE OF NONDISCRIMINATION
I have received a Notice of Nondiscrimination.