Form 1 (cont.)
Your signature below forms a binding agreement between Frontline Medical Doctors (the processor and/or provider of medical services) and the Patient who is receiving medical services, or the Responsible Party for minor patients (those patients under 18 years of age). The Responsible Party is the individual who is financially responsible for payment of medical fees and bills.
If you would like a written copy of the HIPAA laws, please notify our staff. If not, signing below acknowledges that you have waived the written copy.
All co-payments and past due balances are due at the time of service. If your insurance requires any additional co-payment you will be responsible for payment and will be billed for it. As we are a telehealth and telemedicine facilitator, a co-payment may apply. If not eligible for co-payment or no co-payment is listed on your card; we will charge you the specialist co-payment.
**SORRY WE ARE UNABLE TO ACCEPT CHECKS FOR FIRST TIME PATIENTS**
If my Insurance plan is an HMO, I understand that an authorization from my primary care physician may be required for my Insurance company to cover services provided by Frontline Medical Doctors. I agree to contact my PCP to obtain authorization for my visit. If an authorization is not secured, or my plan declines coverage, I will assume responsibility for the charges incurred.
Out of Network Plans:
I acknowledge that it is my responsibility to verify whether Frontline Medical Doctors is in-network with my insurance plan. I agree to pay any balance which results from out-of-network charges.
Authorization to Pay Benefits to the Physician:
All insurance checks that may go directly to the patient MUST be signed over to Frontline Medical Doctors for payment for services rendered. Failure to do this will result in the patient receiving a bill for services. I hereby authorize payment for medical services provided directly to Frontline Medical Doctors.
All patient refunds will be kept as a credit on the patients account toward their next visit unless a refund request is initiated by the patient 24 hrs before appointment time. The following criteria must be met prior to issuing a patient refund: There are no outstanding insurance claims, no outstanding patient balances on the account. Guarantee Express Appointment Date and Times are NON-REFUNDABLE for ANY REASON the day of the appointment.
Returned Check Policy:
If a payment is made on an account by check, and the check is returned as Non-Sufficient Funds (NSF), Account Closed (AC), or Refer to Maker (RTM), the patient or the Patient’s Responsible Party will be responsible for the original check amount in addition to a $35.00 Service Charge. If no payment is received within 90 days, the patient’s account will go to a collections agency and the patient will be discharged from the practice.
COLLECTIONS: If your account is turned over to collection, for any reason, a $25 processing fee will be added to your existing balance due. Please make sure that if a claim becomes your responsibility that you pay the balance according to payment terms of Net 30 days. Our office will send out multiple statements prior to turning your account over to our collection agency. No Prior Notification will be sent to you regarding further action.
Durable Medical Equipment :
As we are an Urgent Care provider and other Health Services facilitator, we have urgent care contracts with most major health insurance companies, In abiding with our contract guidelines, we CANNOT bill insurance companies for DME (Durable Medical Equipment) such as crutches, slings, braces, and extremity immobilizers. We carry these products as a convenience, and they are available to our patients as an out-of-pocket expense. By signing, you acknowledge your understanding that any DME supplies cannot and will not be submitted to your insurance company by you or Southern Flare Urgent Care for reimbursement.
VISIT FOLLOW-UP COMMUNICATION
Text Message and Informed Consent:
In order to enhance patient’s care and experience, Frontline Medical Doctors may contact you after your visit in order to request feedback of your experience by phone call, SMS text message, e-mail, voice mail, or mobile application, some of which may be via automated means. By signing below, you understand and agree to be contacted in the manner with regards to your experience related to this visit, and any future visits.
In the future, you may opt-out of receiving text messages by notifying us in writing (including responding via text message). Standard telephone minute and text charges may apply if we contact you.
CONSENT TO TREAT / RECEIPT OF DOCUMENTS
Consent To Treat:
The above information is true to the best of my knowledge. Insurance policy limitation may not cover today’s visit. I understand and agree that I am responsible for paying any non-covered charges, deductible, and co-payments. I authorize Frontline Medical Doctors or insurance company to release any information required to process my claims or to release any medical records to additional Providers as required. Additionally, I have read and understand my Health Information Patient Privacy Rights.
Receipt of Documents:
BY SIGNING BELOW I ALSO ACKNOWLEDGE THAT I HAVE RECEIVED A COPY OF THE OFFICE FINANCIAL POLICY AND THE HIPAA PRIVACY STATEMENT of Frontline Medical Doctors, a J Rapha Healthcare Services company.
1 (800) 835-0623
6728 Hwy 6 South,
Houston, TX 77083
9:00am - 5:00pm
By Appt Only