Thank you for choosing us as your health care coordination provider. We are committed to providing quality care and service to all of our patients. The following is a statement of our financial policy, which we require that you read and agree to prior to any treatment.
Financial responsibility. Please understand that payment of your bill is considered part of your treatment. Fees are payable when services are rendered. We accept cash, check, credit cards, and pre-approved insurance for which we are a contracted provider, if applicable.
Your responsibility to understand your insurance benefits. It is your responsibility to know your own insurance benefits, including whether we are a contracted provider with your insurance company, your covered benefits and any exclusions in your insurance policy, and any pre-authorization requirements of your insurance company.
We will attempt to confirm insurance coverage. We will attempt to confirm your insurance coverage prior to your treatment. It is your responsibility to provide current and accurate insurance information, including any updates or changes in coverage. Should you fail to provide this information, you will be financially responsible.
We bill insurance first, then you. If we have a contract with your insurance company we will bill your insurance company first, less any copayment(s) or deductible(s), and then bill you for any amount determined to be your responsibility. This process generally takes 45-60 days from the time the claim is received by the insurance company.
You are responsible if we are not contracted with your insurance company. If we do not contract with your insurance company, you will be expected to pay for all services rendered at the end of your visit. We will provide you with a statement that you can submit to your insurance company for reimbursement.
Proof of payment and photo ID are required for all patients. We may ask to make a copy of your ID and insurance card for our records. Providing a copy of your insurance card does not confirm that your coverage is effective or that the services rendered will be covered by your insurance company.
Out-of-network benefits may have additional charges. Please understand some insurance coverages have Out-of-Network benefits that have co-insurance charges, higher co-payments and limited annual benefits. If you receive services are part of an Out-of-Network benefit, your portion of financial responsibility may be higher than the In- Network rate.
I have read the financial policies contained above, and acknowledge a clear understanding of my financial responsibility. I understand that if my insurance company denies coverage and/or payment for services provided to me, I assume financial responsibility and will pay all such charges in full.
I agree a digital copy of this agreement shall be valid as the original.
I hereby irrevocably assign and transfer to Careway Health Medical PA and its affiliates ("Careway Health"), any monies or benefits to which I may be entitled, including benefits/monies from governmental payers such as Medicare, my insurance company, HMO, or other third parties who are financially responsible for my medical care (each a "Plan" and collectively the "Plans"). I authorize and direct Careway Health Medical PA and its physicians, employees, and agents, having treated me, to release to such payers or other third parties who are financially responsible for my medical care, all information needed (including but not limited to medical records, copies of claims and itemized bills) to substantiate payment for my medical care and to permit representatives thereof to examine and make copies of all records relating to such care and treatment. I also appoint Careway Health as my authorized representative to pursue all rights of payment, to ascertain the benefits available, to collect benefits directly from my insurance company and to appeal denials and proceed against my insurance company in any action, including legal suit, on my behalf if for any reason my insurance company refuses to pay my claim. The appointment shall include all rights to recover attorney's fees and costs for such action brought by Careway Health as my assignee. I further agree to provide information as necessary and to cooperate with Careway Health to process and obtain payments. I understand that this document is a direct assignment of my rights and benefits under my Plans.
I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical information about me to release it to the Social Security Administration and Centers for Medicare and Medicaid Services or its intermediaries or carriers for the purpose of payment. I request that payment of authorized benefits related to my care be assigned to Careway Health.
Careway Health is separate from Careway Health Inc., which conducts payment and administrative services for Careway Health.
I understand that I am financially responsible for charges not covered by insurance. I agree to pay all amounts for which I am responsible for medical services rendered in accordance with the rates and terms of Careway Health or as determined by my Plan.
I agree a digital copy of this agreement shall be valid as the original.