This is an agreement between Amarillo Urgent Care LLC, as creditor, and the Patient/Debtor named on this form.
in this agreement the word “you,” your“, and “yours” mean the Patient/Debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words “we,” “us,” and “our,“ refer to Amarillo Urgent Care LLC.
By executing this agreement, you are agreeing to pay for all services that are received.
monthly statement: if you have a balance on your account, we will send you a monthly statement. it will show separately the previous balance, any new charges to the account, the finance charge, if any, and any payments or credits applied to your account during the month.
Payment options if you have no insurance:
1. You choose to pay by _cash _check, _or credit card on the day that treatment is rendered.
2. You may choose whether or not to receive all other treatments involving extra fees (labs, X-rays, and injections). The entire bill must be paid in full on the day of service.
Payment options if you have insurance:
- You choose to pay your deductible of $ _ and any-of-pocket portions at the time services are rendered
by _cash _check _credit card. _ You choose to pay all of your treatment by _cash_check_credit card. We will send your refund, should there be one, within 30 days of payment from insurance. NOTE: Just because you received an explanation of benefits from your insurance
does not mean we have received payment. ,
For visits under $150, payment is expected at the time of service, regardless of insurance.
Payment: Unless other arrangements are approved by us in writing, the balance on your statement is due and payable when the statement is issued, and is past due if not paid by the end of the month.
Charges to Account: We shall have the right to cancel your privilege to make charges against your account at any time. Future visits would then need to be paid at the time of service. ‘
Contracted Insurance: if we are contracted with your insurance company, we must follow our contract and their requirements. If you have a co-pay or deductible, you must pay that at the time of service. it is the insurance company that makes the final determination of your eligibility. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower payment or denial from the insurance company. Non-contracted Insurance: Insurance is a contract between you and your insurance company. We are NOT a party of this contract, in most cases. We will bill your primary insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility. You agree to pay any portion of the charges not covered by insurance. if your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower payment or denial from the insurance company.
Workers compensation: We require written approval/authorization by your employer and/or worker’s compensation carrier prior to your initial visit. If your claim is denied, you will be responsible for payment in full.
Past clue accounts: if your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay all of the collection costs which are incurred. if we have to refer collection of the balance to a lawyer, you agree to pay all Iawyers fees which we incur plus all court costs.
Divorce: In case of divorce or separation, the party responsible for the account prior to the divorce or separation remains
responsible for the account. After a divorce or separation, the parent authorizing treatment for a child will be the parent responsible for those subsequent charges. fI the divorce decree required the other parent to pay al or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent.
Waiver of confidentiality: You understand fi this account is submitted to an attorney or collections agency, fi we have to
litigate in court, or fi your past due status is reported to a credit reporting agency, the fact that you receive treatment at our office may become a matter of public record.
Transferring of Records: You will need to request in writing if you want to have copies of your records sent to another doctor or organization. The amount of the fee is dependent on the number of pages we need to copy. The first 25 pages
will cost you $25.00. Additional pages will cost $.05 per page. You authorize us to include al relevant information, including your payment history. If you are requesting your records to be transferred from another doctor or organization
to us, you authorize us to receive al relevant information, including your payment history.
Finance Charge/Collections: In the event that there is a balance on your account, you are given thirty (30) days to pay the balance ni full. At thirty (30) days your account will be assessed a finance charge of 1.5%. If your account balance reaches
ninety (90) days then your account will be forwarded to a collection agency. Any account referred for collection wil be charged a collection fee of 25% by Amarillo Urgent Care.
Re-billing Fee: Are-billing fee of $5 will be imposed on each account that is over thirty (30) days past-due. We determine your account is past-due by taking the balance owed thirty (30) days ago, and then subtracting any payments or credits applied to the account during that time.
Credit History: You give us permission to check your credit and employment history and to answer questions about your credit experience with us. We have the option to report your account status to any credit reporting agency such as a credit bureau.
Required Payments: Any co-payments required by an insurance company must be paid at the time of service. Because this is an insurance requirement, we cannot bill you for these.
Returned Checks: There is a fee (currently $32.48) for any check returned by the bank.
Personal Injury: If you are being treated as part of a personal injury lawsuit or claim, we require verification from your attorney prior to your initial visit. In addition to this verification, we require that you allow us to bill your health insurance. nI the absence of insurance, other financial arrangements may be discussed. Payment of the bill remains the patient’s responsibility. We cannot bill your attorney for charges incurred due to personal injury case.
Co-Signature: fI this or another Financial Policy is singed by another person, that co-signature remains in effect until cancelled in writing. fI written cancellation is received, it becomes effective with any subsequent charges.
Effective Date: Once you have signed this agreement, you agree to al of the terms and conditions contained herein and the agreement will be in full force and effect.