PATIENT FINANCIAL RESPONSIBILITY STATEMENT

Thank you for choosing Valmed LLC dba Omlife Health Clinic as your healthcare provider. The medical services you seek imply a financial responsibility on  your  part.  This  responsibility obligates you to ensure  payment  in  full  for  the  services  you  receive.  To  assist  in understanding  that  financial responsibility, we ask that you read and sign this form. Feel free to  ask if you have any questions regarding your financial responsibility. If someone else (parent, spouse, domestic partner, etc.) is financially responsible for your expenses or carries your insurance, please share this policy with them, as it explains our practices regarding  insurance billing, copayments, and patient billing. By signing below and/or by receiving  medical  services  from Valmed LLC dba Omlife Health Clinic (“OmLife”), you agree:

  1. You acknowledge and agree to the established policies and procedures of Omlife, including but not limited to this PATIENT FINANCIAL RESPONSBILITY STATEMENT, in effect from time-to-time (“Policies”). You may request a copy of the current Policies from the Business Office Staff. These Policies may be changed from time to time by Omlife, without notice. If there is any conflict between another policy or procedure of Omlife and this PATIENT FINANCIAL RESPONSIBILITY STATEMENT, this Statement shall
  1. You are ultimately responsible for all payment obligations arising out of your treatment or care and guarantee payment for these services. You are responsible for deductibles, co-payments, co-insurance amounts or any other patient responsibility indicated by your insurance carrier or our Policies, which are not otherwise covered by supplemental
  1. You are responsible for knowing your insurance policy. For example, you will be responsible for any charges if any of the following apply: (i) your health plan requires prior authorization or referral by a Primary Care Physician (PCP) before receiving services at Omlife, and you have not obtained such an authorization or referral; (ii) you receive  services  in  excess  of  such authorization or referral; (iii) your health plan determines that the services you received at Omlife are not medically necessary and/or not covered by your insurance plan; (iv) your health plan coverage has lapsed or expired at the time you receive services at Omlife; or (v) you have chosen not to use your health plan If you are not familiar with your plan coverage, we recommend you contact your carrier or plan provider directly.
  1. You will be required to follow all registration procedures, which may include updating or verifying personal information, presenting verification of current insurance, providing signatures, and paying any co-pays or other patient responsibility amount at each visit. Your card or other insurance verification must be on file for your insurance to be billed. If we do not have your card on file, or are unable to verify your eligibility for benefits, you will be treated as a self-pay patient. As a self-pay patient, our fee is expected to be paid in full at the time of service. If the insurance card or other necessary information is furnished after the visit, we may file a claim with your insurance; and, if paid in full by your insurance, you will be If you are not prepared to make your co-pay or other patient responsibility amount, your visit may be re-scheduled by Omlife.
  1. By signing below, you authorize Omlife to verify your insurance benefits and submit your claim to your insurance carrier or other plan provider. You agree to facilitate payment of claims by contacting your insurance carrier or other plan provider when necessary. Without waiving any obligation to pay, you assign to Omlife, for application onto your bill for services, all of your rights and claims for the medical benefits to which you, or your dependents are entitled, under any federal or state healthcare plan (including, but not limited to, Medicare or Medicaid), insurance policy, any managed care arrangement or other similar third-party payor arrangement that covers health care costs and for which payment may be available to cover the cost of the services  provided to you. You authorize Omlife and associated physicians, staff, and hospitals to release patient information acquired in the course of your examination and/or treatment including but not limited to any and all medical records, notes, test results, x-ray reports, MRI reports or other documents related to your treatment (including itemization of any charges and payments on my account) that is deemed necessary to process this claim to the necessary insurance companies, third party payors, and/or other physicians or health care entities as they require to participate in your care. It is important to notify us as soon as possible of any changes related to your insurance Failing to do so may result in unpaid claims, and you will be responsible for the balance of the claim. Omlife does not accept responsibility for incorrect information given by you or your insurance carrier or other plan provider regarding your insurance benefits or benefit plans.
  1. If your insurance carrier does not remit timely payment on your claim, you will be responsible for payment of the charges within the terms set forth herein. Once your insurance carrier processes your claim, we will bill you for any remaining patient responsibility deemed by your insurance If any payment is made directly to you for services billed by us, you agree to promptly submit same to Omlife until your patient account is paid in full. If you make a payment that results in a surplus on your account, you authorize Omlife to apply the overpayment to any other account for which you are financially responsible, including your account, a member of your family’s or dependent’s account, or on any account for which you are a Financial Responsibility Party, and any remaining balance will be returned to the payor.
  1. You will be mailed a billing statement that contains the total cost of your service(s) or procedure(s) received during your visit(s). You may generally expect this billing statement within twenty (20) days after your insurance company has responded to a submitted You must notify us of any errors or objections to the billing statement within thirty (30) days or they will be deemed accurate, and the fees and expenses shall be deemed reasonable and necessary for the services incurred. If there is a problem with your account, it is your responsibility to contact the Patient Accounts Staff to address the problem or to discuss a workable solution.
  1. Whether or not you have insurance or are self-pay, payment of any account balance is due at our Patients Account Offices in Dubuque, Iowa within thirty (30) days of receipt of your billing statement. If any balance on your account is over ninety (90) days past due, your account will be in default and auto referred to a collection The balance of any account not paid within ninety (90) days will begin to accrue interest at the rate of 1.5% per month or the maximum allowed by applicable law, whichever is lower. For small balances, between $4.01 to $25.00, we may stop sending billing statements any time after the initial statement, but you understand that the amount shall remain due and owing until paid in full.
  1. We accept payment by cash, money order, debit cards or credit. You may pay with a credit card or debit card, including Visa, Mastercard, and Discover (“credit card”). Your payment with a credit card may be made in person, by mail, or by calling the number provided on your billing statement. All regular credit card rules will apply. Once authorization on the submitted information is received, your credit card will be If your charge is not accepted, you will be notified. You are responsible for all late charges or penalties resulting from the late receipt of any payment. Your information is used solely to process your payment. While processing your credit card payment, only the last 4 digits of your credit card are viewable by Omlife personnel. We do not otherwise store your sensitive credit card information.
  1. Managed Care (HMO, PPO, ). All managed care co-payment amounts are due at the time of service. If your insurance plan requires a referral authorization from a primary care physician, you are responsible for presenting this at your initial visit. If you request an office visit without a referral authorization, your insurance plan may deem this as “out of network” or “non-covered” treatment, and you will be responsible for a larger amount or all of the charges. You acknowledge that it is your responsibility to be aware of what services are covered and you agree to pay for any service deemed to be non-covered or not authorized by the plan.
  1. Omlife is a participating provider with the Medicare program and accepts as payment the Medicare allowable, patient deductible and/or 20% co-insurance. Medicare or secondary carriers do not cover some procedures and supplies. Please make certain you understand which aspects of your treatment are covered before proceeding. You understand that you will be responsible for your annual deductible, the co-payment, and any non-covered services specified by Medicare. By signing below, you request that payment of authorized Medicare benefits be made on your behalf to Omlife for any services furnished to you by Omlife.
  1. If you are a Medicaid patient, you must present a valid eligibility card at the time of registration and prior to the time of service. Your eligibility status will be verified monthly. Without verification of coverage, you will be responsible for the full/entire balance of your account. As a courtesy to you, your account will be billed to Medicaid when we receive all necessary information. You are responsible for non-covered portions and spend-down requirements associated with your individual coverage. If at any time you are not eligible for Medicaid coverage and wish to be seen, you will be treated as a self-pay patient and must make payment at the time of service.
  1. Workers’ Compensation Cases. Charges for services incurred as a result of a verified work- related injury will be treated as workers’ compensation, and we will bill the workers’ compensation carrier as a courtesy. You must provide necessary information to bill the carrier. You are responsible for the completion of information with the employer and approval of the workers’ compensation claim. In case your workers’ compensation claim is denied, you will also provide us with your medical insurance information. If your claim is denied, we will bill your regular medical insurance carrier. When the claim is no longer pending and any portion of your claim is ultimately resolved against you by workers’ compensation and your medical insurance, you will be required to pay all amounts due within thirty (30)
  1. Third Party Liability If you receive treatment as a result of a third party liability injury (for example: motor vehicle accidents, premises liability, or other general liability claims against third parties), the balance for services rendered is considered due in full at the time of the service. Because Omlife does not protect charges incurred relating to or arising out of third party liability, we will not accept a delay in payment due to settlement disputes and/or litigation. We will not accept a letter of protection from an attorney as a guarantee of payment or assignment of third party insurance payments. Omlife  cannot  act  as  administrator  to  resolve   financial arrangements. We may  agree to bill a third party insurance company of an at-fault party involved in an accident as a courtesy to you. To bill your claim directly, you must provide us all  necessary information to confirm coverage for these payments with the auto/third-party carrier. We will also collect information about your personal medical insurance in case the auto/third-party carrier denies your claim. Regardless of whether we submit your claim to third-party insurance, as the patient, you are ultimately responsible for payment.
  1. Ancillary Services. You may receive ancillary medical services while a patient of  Omlife such as: anesthesia, interpretation of tests, neuropsychological testing, imaging services (e.g., x- rays, MRIs) and pathology specimen examination. By signing below, you understand that some physicians may not provide services in your presence, but are actively involved in the course of diagnosis and treatment. You authorize payment directly for these services under the policy(s) or plan(s) issued to you by your insurance carrier. You may incur additional charges as a result of these ancillary services. You agree to pay all charges due with respect to such services after benefits paid on your behalf by any third-party are credited to your
  1. Additional Charges. Patients may incur and are responsible for the payment of additional charges at the discretion of Omlife including but not limited to: (i) charges for returned checks; (ii) charges for a missed appointment without 24 hours advance notice; (iii) charges for extensive phone consultations and/or after-hours phone calls requiring treatment, or prescriptions; (iv) charges for copying and distribution of patient medical records; (v) charges for extensive forms preparation or completion; or (vi) any costs associated with collection of patient balances, all as allowed by law.
  1. Non-payment on Account. Should collection proceedings or other legal action become necessary to collect an overdue or delinquent account, you understand that Omlife has the right to disclose to an outside collection agency or attorney all relevant personal and account information necessary to collect payment for services rendered. You are responsible for all costs of collection including, but not limited to: (i) late fees and charges and interest due as a result of such delinquency; (ii) all court costs and fees (but only to the extent allowed by law); and (iii) a collection fee to be charged under separate agreement with a third-party collections agency, either as a flat fee or computed as a percentage of the total balance due up to the maximum allowed by applicable law, and to be added to the outstanding balance due and owing at the time of the referral to the third party collection agency. You acknowledge that any such interest assessed on the account will be a late fee as a result of default or delinquency on your account, and is not deemed interest as part of a credit transaction. If your account is referred to a collection agency, attorney, court, or the past due status is reported to a credit reporting agency, it may have an adverse effect on your credit history; and related portions of your account, including the fact that you received treatment at our offices, may become a matter of public record. Failure to comply with any of these policies may also result in a Credit Withdrawal of Care. By signing below, you agree, on behalf of yourself, your legal representatives and next of kin, that the jurisdiction, venue, and choice of law of any dispute or state court action related to the health care services or the billing provided by Omlife shall, at the option of Omlife, be subject to the exclusive jurisdiction of (i) the appropriate court in the state where the provider of the disputed services is physically located when the services are rendered or (ii) where you reside.
  1. Minor Patients. The parent/guardian of a minor is responsible for payment of the minor’s account balance. A minor who is not accompanied by a parent/guardian will be denied any non- emergency treatment unless charges for the treatment have been pre-authorized. Responsibility for payment of treatment of minor children, whose parents are divorced, rests with both parents. Any court-ordered responsibility judgment must be determined between the individuals involved, without the inclusion of
  1. Authorization to Contact. You authorize Omlife personnel to communicate by mail, answering machine messages, and/or e-mail according to the information  provided  in  your patient registration information. Omlife, or any agent or servicer of your patient account, may use any information you have provided, including contact information, e-mail addresses, cell phone numbers, and landline numbers, to contact you for purposes related to your account, including debt collection. You authorize Omlife to use this information in any manner consistent with the information you have provided, including mail, telephone calls, e-mails, or text messages. You expressly consent to any such contact being made by the most efficient technology available, including automatic dialing/e-mailing or similar equipment, or pre-recorded or other messages, even if you are charged for the
  1. Financial  Responsibility         If   this   or   a   separate   Omlife   Financial Responsibility Statement is signed by another person, on your account, then that co-signature remains in effect until cancelled in writing. Cancellation in writing shall become effective the date after receipt, and shall apply only to those services and charges thereafter incurred. By signing as Financial  Responsibility  Party,  you  hereby  guarantee  the  full  and  prompt  payment  to  Omlife of all indebtedness of Patient to Omlife, whether now existing or hereafter created (the “Indebtedness”); and you further agree to pay all expenses, legal or otherwise, incurred by Omlife in collecting the Indebtedness, in enforcing this guaranty, or in protecting its rights under  this guaranty or under any other document evidencing or securing any of the Indebtedness. This guaranty shall be a continuing, absolute and unconditional  guaranty,  and  shall remain  in  force and effect until any and all said Indebtedness shall be fully paid. There shall be no obligation on    the part of Omlife at any time to first exhaust its remedies against Patient, any other party, or any other rights before enforcing the obligations of Financial Responsibility Party.

Acknowledgement

By signing below, each of the undersigned acknowledges that: (i) I have been provided a copy of the Valmed LLC dba Omlife Health  Clinic  PATIENT  FINANCIAL  RESPONSIBILITY  STATEMENT;  (ii)  I  have read, understand, and agree to their provisions and agree  to  the  specified  terms;  (iii)  I agree to pay all charges due (or to become due) to Omlife for the below Patient’s care and treatment, including co-payments and deductibles, as required or provided pursuant to my insurance plan and/or the insurance plan of another, as applicable; (iv) benefits, if any, paid by a third-party will be credited on the Patient account; (v) regardless of my insurance status  or  absence of insurance coverage, I am ultimately responsible for the balance on the account for any services rendered; (vi) if I failed to make any of the payment for which I  am  responsible  in  a timely manner, I will be responsible for all costs of collecting the money owed, including court  costs, collection agency fees, and attorneys’ fees (to the extent allowed by law); and (vii) failure to pay when due may subject me to late payment charges and can adversely affect my credit report.

I further agree that a photocopy of this Patient Responsibility Financial Statement shall be as valid as the original.

ONCE I HAVE SIGNED THIS AGREEMENT, WHETHER BY ORIGINAL, FACSIMILE OR ELECTRONIC (“.PDF”) SIGNATURE, I AGREE TO ALL OF THE TERMS AND CONDITIONS CONTAINED HEREIN AND THE AGREEMENT SHALL BE IN FULL FORCE AND EFFECT.

 

____________________________________________________                                                                               ____________________________________________________________________ 

Patient/Responsibility Party/Guardian          Date                                                                               Date of Birth

 

Waiver of Patient Authorizations

 

I do not wish to have information released and prefer to pay at the time of service and/or to be fully responsible for payment of charges and to submit claims to insurance at my discretion.

 

____________________________________________________                                                                     ______________________________________________________________________

Signature of Patient or Guardian                                                                                                     Date