Some health insurance carriers require the patient to pay a co-pay for services rendered. It is expected and appreciated at the timethe service is rendered for the patients to pay at EACH VISIT. Thank you for your cooperation in this matter.
Patient/Guarantor Signature Date
Workers Compensation Injury:
If you believe you are being seen for an injury/illness because of your job, you need to provide written authorization from your employer to confirm this, & direction from your employer on who ALTMED should bill. If you do not provide this information at the time services are provided, ALTMED
may bill you &/or your insurance company.
If you are unable to meet your financial obligations, payment arrangements can be made. Financing options may be available. Contact our Billing Department to discuss payment options, before your account becomes overdue. In cases of financial hardship, please ask about the practice’s hardship policy. Hardship policies vary by practice; limitations & restrictions apply.
Patients generally may pay by cash,money order or personal credit card. This includes cards for "flexible spending accounts" &/or “health savings accounts”. Card information may be kept on file by ALTMED to facilitate billing. If you have a credit balance, ALTMED may apply it to any outstanding balances on your account or the accounts of your dependents. Some locations may restrict payment by cash or check.
Fees Assessed by ALTMED
You may be charged fees for: (1) Returned Checks, (2) Completion of Forms (e.g. Disability or Family Medical Leave), (3) Copies of Medical Records, & (4) Failure to Cancel Appointments in Advance ("No Show"). Notify ALTMED of cancelations at least 48 hours in advance to avoid No Show fees. The No Show fee may be assessed up to the amount in our current Fee Schedule.
Termination of Services
If you fail to keep your account current or fail to respond to 3 notices to the address we have on file for you, you agree that ALTMED may terminate your relationship with any or all its offices. In such event, you agree that you are no longer a patient, & ALTMED will not offer you a future appointment. You will have deemed yourself as terminating our relationship if you do not obtain services from ALTMED for 3 years or if you notify us that you will no longer be a patient.Acceptance back into the practice is at the discretion of ALTMED. ALTMED may terminate your relationship with us forother reasons, such as disruptive behavior or non compliance with care plan, or for no reason.
Authorization to Release of Medical Information
The authorizations described in this Financial Policy may include records about infectious diseases & drug & alcohol abuse treatment. You authorize the release of information by ALTMED to third party payers (including insurance companies & their contractors), health care institutions, physicians & others involved in your medical care. You agree that as appropriate for your care, ALTMED may share information with family members & friends. You agree that ALTMED may provide your medical records to third party payers, review agencies, employers, welfare departments & others for treatment, payment or healthcare operations purposes.
ALTMED participates in one or more Health Information Exchanges. Healthcare providers can use these electronic networks to securely
provide access to your health records for a better picture of your health needs. With this authorization, you agree that ALTMED and other healthcare providers, may allow access to your health information through the Health Information Exchanges for treatment, payment or other healthcare operations. This is a voluntary agreement. You may opt out at any time by notifying an ALTMED Practice Manager or Compliance Officer.
You opt out notice needs to be in writing.
Accidents & Motor Vehicle Injuries
ALTMED ’s providers have the discretion to decide whether to see patients injured in motor vehicle accidents or for other liability injuries. ALTMED ’s providers also have discretion to decide whether to bill the liability insurance involved (i.e. home, auto, etc.). ALTMED does not have to agree to subrogate or accept liens. You must provide accurate information about the injury & may be required to complete an injury questionnaire. In all cases, you bear responsibility for the costs of your care & must pay them promptly at any time that location decides which may include requiring
payment in full at time of service.
I have read this information carefully & agree that everything in this Agreement applies to current & future health care services provided by
ALTMED.I acknowledge that ALTMED may change these terms without notice to me.
Interest and Attorney's Fees:
For any past due amounts, ALTMED shall be entitled to payment from you of interest at the rate of 2% per month (24% per annum), & you shall be responsible for all costs & expenses incurred in efforts to collect past due amounts from you, including interest charges, court costs, & reasonable attorney's fees. If a check is returned for insufficient funds, all charges incurred by ALTMED shall be your responsibility.
Patient/Guarantor Signature Date: