Financial Responsibility Form

Please correct the errors described below.

3775 45th Ave.
Columbus, NE 68601
402-564-7200
Fax: (402) 564-7210

You must review and sign the Financial Responsibility Form which will be kept in your file. References herein to the "patient," "you" or "your" mean: (A) the parent or other adult guarantor who signs this Form pertaining to any minor patient, or, (B) if the patient is an adult and signs this Form, to the patient himself or herself. This Form applies to all services to the Patient on or after its date, unless and until modified in writing by CCH Pediatric Clinic P.C. or a new Form is signed by you and CCH Pediatric Clinic P.C.

Patient Responsibilities:

It is the patient's responsibility to provide CCH Pediatric Clinic P.C. ("us" or "our office") with complete and accurate information and to promptly notify us of any changes in information upon registration.

All co-pays and deductibles are due at the time of service. If you are not prepared to pay, please understand that your appointment may be rescheduled. If you do not have insurance or have an out of network insurance, payment is expected at the time of service, unless otherwise specifically arranged and confirmed by us in our records. For your convenience, we accept Visa, Master Card and Discover.

If your insurance requires a referral or prior authorization for services, you must cause us to receive the completed form before your appointment or you must be prepared to present it at the time of your service. Without this, you will either be rescheduled or you agree to be prepared to pay for the service in full.

As a courtesy we will attempt to file your insurance (or in cases where we may be required by law or insurance contract), but you are expected to pay co-insurance and deductible amounts within 60 days from the time your claim is processed. If you are unable to pay the balance in a timely manner, you must contact our billing office to establish a payment arrangement based upon your account balance. An example of a payment plan consists of regular minimum payment amounts of $50 per month, but your circumstances may not qualify you for this example. You hereby acknowledge that any payment plan is not an extension of credit to you but instead is a workout of debt.

If you fail to notify our office of any address change and we are unable to locate you, we intend to turn over your account to a collection agency immediately.

You will be mailed an initial statement requesting payment. To keep your account current and open you must pay immediately or make payments as arranged in our payment plan. If we do not receive any response, we will attempt to send to you a second statement (past due) requesting payment. If we still receive no satisfactory response, we will attempt to send to you a final notice letter requesting payment within 15 days will be mailed. This will typically be our final attempt prior to being referred to a collection agency.

If at any time, you fail to adhere to your payment arrangements, or you do not respond in a way we deem cooperative to our collection efforts, your account may be assigned to a collection agency. If your account is ever referred to a collection agency, you will no longer be treated by the physicians until specific payment arrangements have been made. You will then be placed on a cash only basis. All fees for services must he paid at the time of service. You hereby acknowledge that our policy is appropriate and represents good faith by us.

"Fully Pay" as used in this document means payment to our office in full according to our office's regular billed rates and terms. You agree, whether you sign as agent or as patient, that in consideration of the services to be rendered to the patient, payment in full is due after services are rendered and upon billing. You agree to promptly Fully Pay our office.

Patients whose insurance requires lab to be performed at a certain lab must inform the receptionist or nurse at the time of the service. If we are not informed, you will be responsible for the charges incurred. All lab specimens collected at our office are processed at Columbus Community Hospital unless other specific arrangements have been made at the time of service.

I consent to you and your agents and independent contractors using for appointment, billing, debt collection and any other purposes any wireless/cell phone numbers and email addresses I provide to you. This includes automated calls, pre-recorded/artificial voice messages, and all other calls, texts and emails. If I discontinue use of any phone number provided, I shall promptly notify you; I hereby indemnify you and your agents and independent contractors from any expenses or other loss arising from any failure to notify.

Our Office's Conduct:

Our office will attempt to code claims for your services and handle them as follows: If your insurance company has a contract with us, we will endeavor to file or otherwise handle claims as allowed by that contract. If your insurance company has no contract with us, we will endeavor to file insurance claims as a courtesy; however, you understand that this does not relieve you of your financial obligation to pay any portion that is not paid by insurance for any reason, such as but not limited to amounts deemed uncovered by the company or a company evaluation unacceptable to us.

We typically will send a statement of your account to you every month as long as there is a balance due of $3.00 or more on your account.

If your insurance company fails to notify our office of your claim's processing within 45 days, our billing office will endeavor to contact them to learn the status of the claim.

If your insurance company processes your claim incorrectly, we typically will attempt to submit additional information if requested and/or appeal this claim and try to resolve the matter in a timely manner.

When an overpayment occurs on an account, steps will be taken per our Patient Refund Policy.

All inquiries you make regarding your account will be answered honestly. If your question requires information not readily available, our billing office will seek additional data and resolve the issue promptly. If this is not possible, you will be informed of the delay and kept up to date on the progress.

Our office typically will not attempt any overall resolution to matters delaying payment of the account due to legal separations, divorces or third-party litigations, and such matters will not excuse you from causing us to receive timely payment. Nothing in the document waives any medical lien or assignment of benefits rights.

We review our fees annually and adjust them according to the Health Care Finance Administration and American Medical Association guidelines. All our fees fall within the acceptable ranges by our contracted insurance companies and most other insurance companies.

Our office may modify or waive from time to time aspects of this document for a particular account. Any such modification or waive requires approval by our office's Financial Controller or Practice Administrator, or the specific designee of any of them. Nothing in this paragraph precludes our office, through any other authorized representative, from settling legal disputes.

Other:

The fact that you sign this Form does not necessarily reduce the liability of any other individual to us. If you have questions regarding our financial policy, please contact our office at 402-564-7200.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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