360infusioncenter.com - Patient Insurance OPT out Policy Form

Patient Name

First NameLast Name

It is our goal to provide you and your family the very best service possible. As a service to our patients we are participating in a number of health plans, thereby making our services accessible to as many patients as possible, we also want to make our services affordable to you for a Non-Insurance Based Program.

Please initial each line item reviewed and sign below to confirm your understanding of our OPT OUT policy.

(Initials)    This confirms and identifies your understanding that we will NOT BILL your healthcare insurance provider for the 360 Infusion Center infusion services and you OPT OUT of this method for payment to 360 Infusion Center. In this case we are not permitted to bill your insurance for any of our health care services. All payments made to 360 Infusion Center for health infusion services will be directly billed to you (the patient) as per our Cash Pay Plan.

PLEASE REVIEW and INITIAL FOR “OPT IN CASH PAY “ BELOW:

(Initials)  You are OPTING FULL IN as a CASH PAY customer only. This includes the Provider Visit(s) and 360 Infusion Center health infusion services, whereas you understand our cash pay fee schedule is based upon Medicare allowable rates and is provided to you at the time or before your visit, CASH PAYMENT IS DUE AT THAT TIME OF SERVICE or through our Recurring Payment Option(s). We will not bill your insurance for the Provider Visit. You will be responsible for payment for the Provider Visit(s) and services as deemed necessary.

(Initials)   Below is our NO SHOW /CANCELLATION Policy outline for your understanding:

1.) We request out of respect for other patients waiting for appointment(s), please notify our office at least 24 Hours prior to your appointment date if you must CANCEL OR RESCHEDULE. We are available to assist with rescheduling.
2.) If you do not contact our office, and are a NO SHOW at your scheduled procedure date/time you MAY BE BILLED A $10.00 cancellation/no show fee due to the cost involved for preparations of your scheduled appointment.

PATIENT ACKNOWLEDGEMENT

We sincerely hope these policies promote our overall goal of transparency and team-oriented health care. Please feel free to let us know if there are any items we can improve to make the administrative side of our practice as painless and easy for you as possible.

By my signature below, I acknowledge to have read the above polices and agree to the outlined terms. I understand my responsibilities and the consequences for violation of the financial or cancellation responsibilities. I was given opportunity to ask questions regarding the financial and cancellation policies and understand their impact on my relationship to the practice.

Patient Signature (or legal guardian, please identify below):

Date:

Date

If signed by a legal guardian above, please print name and relationship to patient:

Relation:

INSURANCE OPT OUT