PRIVACY & BILLING PROCEDURES
AUTHORIZATION & ACKNOWLEDGEMENT
These authorizations, acknowledgements and waivers cover all services rendered to the above patient for today and all future dates of service. You may submit written revocation of the authorization.However, your decision to revoke the authorization will not affect or undo any events that occurred before you notified us of your decision to revoke.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Access 365 Urgent Care, LLC (A365UC) and Back In Action Medical Center, LLC (BIAM)reserve the right to modify the privacy practices outlined in the Notice of Privacy Practices. I have had the opportunity to read or have received a copy of the Notice of Privacy Practices for the patient outlined above.
AUTHORIZATION TO TREAT & BILL
I give consent and authorization to A365UC and/or BIAM to examine and provide all routine medical care, diagnostic procedures, disposing of any specimens or tissue taken from my body, and provide treatment in the judgment of the medical provider, necessary or beneficial to my health and well-being with no guarantees expressed regarding the results of examination and treatment by aforementioned facility.
I authorize the release of any medical and demographic information necessary to process all claims. I authorize payment of medical benefits to A365UC and/or BIAM for all services performed.
I understand that I am responsible for all charges incurred at the time of service unless other arrangements were made prior to being treated. I will pay any deductible, co-payments, and any amounts denied or not covered by insurance. I understand it is my responsibility to check with myinsurance carrier prior to my visit for covered and non-covered benefits and also whether or not A365UC and/or BIAM visit will be paid with my innetwork or out-of-network benefits billed as urgent care place of service (POS 20).
I understand that if I do not provide complete and accurate billing/insurance information at the time of service and this lack of information prevents A365UC and/or BIAM from collecting from my insurance company, I will be responsible for the full charges. If a referral or additional forms are required by my insurance company, I understand I am responsible for providing A365UC and/or BIAM with a referral within 48 hours of my visit and/or complete all insurance required forms in a timely manner, or I may be responsible for all charges.
Collection Fees: If payment is not made as agreed upon, the account will be turned over for collection. The patient and/or guarantor, shall be responsible for and agree to pay all reasonable cost of collection including, but not limited to, reasonable collection agency fees, attorneys fees,and court costs.
Jurisdiction and venue: If any suit must be filed to collect an unpaid balance on an account, patient, and/or guarantor, agrees that such suit may be brought in courts of Martin County, Florida, and waives any objection to jurisdiction or venue.
Assignment & Release: I hear by request and assign directly to A365UC and/or BIAM all medical benefits, if any otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, including collection fees and/or interest that may accrue, whether or not paid by insurance. I hereby authorize the provider to release all information necessary to secure the payment of benefits unless written notice is given to revoke this authorization. I authorize the use of a copy of this signature is as valid as the original signature on all of my insurance submissions. Co-pays and Quick Pay fees are due at the time of service. All account balances will be the patient's and/or guarantor's responsibilitynafter processing of insurance if applicable, and may be assessed and $15.00 statement fee per invoice. Full balance is due within 15 days or upon receipt of the first invoice.