Payment Guarantee: For services rendered by American Health Network (“AHN”), you guarantee payment of your account at the time services are provided for any & all costs that are not paid by an insurance carrier, government payer (including Medicaid), & other third party payer (together, referred to as “PAYER”), including if your PAYER denies a claim after first approving it. You understand that any out-of-network charges may be your responsibility as determined by your PAYER. You acknowledge that you will be responsible for paying AHN for items & services provided to your dependents under these same policies, terms, & conditions whether or not you are listed as the “Responsible Party” on the Patient Data Sheet. The person listed as the “Responsible Party” on the Patient Data Sheet will also be responsible to AHN for payment. All charges incurred are your responsibility.
Assignment of Benefits: To the extent there is PAYER coverage for payment of services, you agree that all medical & related benefits PAID by PAYER will be irrevocably assigned to AHN on your behalf.
Billing Information: You must provide complete & accurate information & notify us of changes to any of your information (address, phone number, insurance). We will use reasonable efforts to submit claims to your PAYER & promptly provide you with our statements. If for any reason, amounts that you owe are not paid promptly, including if a statement is returned as undeliverable, you may be referred to a collection agency. Bring your government-issued photo identification & insurance cards to every visit. Otherwise, you may be required to pay in full that day.
Medicare Agreement: If you have Medicare coverage, you acknowledge that payment of benefits will be made to you or on your behalf for any items or services furnished to you by AHN (or the party who accepts assignment), including your physician services. You authorize any holder of medical or other information about you to release to Medicare & its agents, any information needed to determine these benefits or any benefits for related services.
Payment terms: We require payment at the time of your office visit. This includes amounts for co-pays, coinsurance, deductibles & past-due balances unless previous arrangements have been made with our billing department. If you fail to make payment at the time of service, we may charge extra processing fees in recognition of billing & collection expenses.
Interest and Attorney's Fees: For any past due amounts, AHN shall be entitled to payment from you of interest at the rate of 1.5% per month (18% per annum), & you shall be responsible for all costs & expenses incurred in efforts to collect past due amounts from you, including interest charges, court costs, & reasonable attorney's fees. If a check is returned for insufficient funds, all charges incurred by AHN shall be your responsibility.
Workers Compensation Injury: If you believe you are being seen for an injury/illness as a result of your job, you need to provide written authorization from your employer to confirm this, & direction from your employer on who AHN should bill. If you do not provide this information at the time services are provided, AHN may bill you &/or your insurance company.
Self Pay Services: If you do not have insurance or if the services are not covered by your PAYER, you will receive a 15% discount for professional services rendered, when payment is made in full at the time services are rendered. This discount does not apply to amounts that you owe due to co-pays, coinsurance or deductibles.
Payment Options: If you are unable to meet your financial obligations, payment arrangements can be made. Financing options may be available. Contact our Billing Department to discuss payment options, before your account becomes overdue. In cases of financial hardship, please ask about the practice’s hardship policy. Hardship policies vary by practice; limitations & restrictions apply.
Making Payments: Patients generally may pay by cash, money order, check or personal credit card. This includes cards for "flexible spending accounts" &/or “health savings accounts”. Card information may be kept on file by AHN to facilitate billing. If you have a credit balance, AHN may apply it to any outstanding balances on your account or the accounts of your dependents. Some locations may restrict payment by cash or check.
Fees Assessed by AHN: You may be charged fees for: (1) Returned Checks, (2) Completion of Forms (e.g. Disability or Family Medical Leave), (3) Copies of Medical Records, & (4) Failure to Cancel Appointments in Advance ("No Show"). Notify AHN of cancelations at least one business day in advance to avoid No Show fees. The No Show fee may be assessed up to the amount in our current Fee Schedule.
Termination of Services: If you fail to keep your account current or fail to respond to 3 notices to the address we have on file for you, you agree that AHN may terminate your relationship with any or all of its offices. In such event, you agree that you are no longer a patient, & AHN will not offer you a future appointment. You will have deemed yourself as terminating our relationship if you do not obtain services from AHN for 3 years or if you notify us that you will no longer be a patient. Acceptance back into the practice is at the discretion of AHN. AHN may terminate your relationship with us for other reasons, such as disruptive behavior or non-compliance with care plan, or for no reason.
Authorization to Release of Medical Information: The authorizations described in this Financial Policy may include records about infectious diseases & drug & alcohol abuse treatment. You authorize the release of information by AHN to third party payers (including insurance companies & their contractors), health care institutions, physicians & others involved in your medical care. You agree that as appropriate for your care, AHN may share information with family members & friends. You agree that AHN may provide your medical records to third party payers, review agencies, employers, welfare departments & others for treatment, payment or healthcare operations purposes.
Continuing Agreement: I have read this information carefully & agree that everything in this Agreement applies to current & future health care services provided by AHN. I acknowledge that AHN may change these terms without notice to me.
Patient (or representative) agrees to these terms as evidenced by signature on Patient Data Sheet.