Consent to Leave Messages
Please review this information and sign at the end of the document. By signing this document, the patient/responsibile party is accepting financial responsibility for all services provided.
Ranch View Family Medicine (RVFM) will bill your insurance as a courtesy if the company is within the United States. We may provide an estimate of what your insurance company may pay. The insurance company makes the final determination of your eligibility and benefits.
It is your responsibility to notify our office of any patient information changes including address, name, and insurance information. We expect that you will provide your current insurance card at every office visit.
1. I (patient or financially responsible party) will disclose all insurance information including primary and secondary insurance at the time of service. Failure to provide complete insurance information may result in my responsibility to pay the entire bill.
2. I agree to pay any portion of the charges not covered by my insurance within 10 days of the statement date. If RVFM is out of network with my insurance company, I will be responsible for any charges above what is paid by my insurance up to the RVFM set fee amount. If my insurance pays me directly, I agree to forward the payment to RVFM immediately.
3. I am responsible for any co-payments, co-insurances, deductibles, plus any balance due on non- covered services not paid by my insurance at the time of service. Payments are required within the state's time limitation for paying healthcare claims. The co-payment, co-insurance or deductible requirement cannot be waived. We accept cash, check or credit cards.
4. If you have a high deductible plan we expect that you pay $75.00 at time of service.
If you do not have insurance or you choose to not utilize your insurance, we offer a self-pay discount of 40% if payment is received in full at the time of service.
1. I am responsible for obtaining a referral, if required by my policy.2. I understand if I fail to obtain the referral and/or preauthorization there may be a lower payment or no payment from the insurance company. I will be responsible for the balance due.
I understand I may be charged a fee of $50.00 if I miss or cancel an appointment within 3 hours of the scheduled appointment.
I understand I will be responsible for a fee of $25.00 for a returned check. This will be applied to my account in addition to the insufficient funds amount. All future payments must be paid with a debit/credit card or cash.
Medical Record Copies
I understand I will be responsible for a fee that follows Colorado Department of Health and Environment standard for requesting a copy of my health records.
By signing this document, I (the parent, guardian) accept financial responsibility for all services provided by RVFM, regardless of who is the subscriber of the insurance policy.
1. RVFM accepts Visa, Mastercard, debit cards and checks.
2. I understand that I am requested to put a credit, debit or HSA card on file. This information is kept strictly confidential and will only be used for payment of fees to RVFM. The card on file will not be charged until the insurance company has reviewed the claim. By processing insurance first, patients will know their exact out-of-pocket responsibility. After the insurance company has completed processing the claim, I will receive an email informing them of the actual amount owed. The email will explain that the card on file will be charged in 3-5 days unless I contact the billing office at 303-346-8828.
3. I understand the Financial Information may be provided to the financially responsible party (Guarantor), Subscriber, or the party paying the bill.
4. I understand the financially responsible party (Guarantor) is responsible for payments.
5. I understand upon default, I am responsible for 24% per annum interest, cost of collections, and attorney fees, even if no lawsuit is filed.
6. We currently allow 6 months for a balance to be paid in full. If for any reason your account defaults to collections you are subject to dismissal from the practice. Extended payment arrangements are available if needed.
Please contact our Billing Office at 720-369-4098 to discuss payment options, or with any questions or concerns.
I have read the policies above and understand and agree to this Financial Policy.
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:
• Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
• Obtaining payment from third party payers (e.g. my insurance company);
• The day-to-day healthcare operations of your practice.
I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.
I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.
I understand that I may revoke this consent, in writing, at any time, However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
(Copies of this consent are available upon request)