This is an agreement between Connecticut Asthma & Allergy Center, LLC, and the Patient/Parent of the minor patient named on this form. In this agreement, the words "you," "your," and "yours" mean the Patient/Parent of a minor patient. The word "account" means the account that has been established in your name or your minor child’s name to which charges are made and payments credited. The words "we," "us," and "our" refer to Connecticut Asthma & Allergy Center, 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. Unless other arrangements have been approved by us in writing, the balance is due and payable in full upon receipt
.• Contracted Insurance: Insurance is a contract between you and your insurance company. We will bill your primary insurance company as a courtesy to you. 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. You agree to pay any portion of the charges not covered by insurance.
• Non-contracted Insurance/Out of Network: If you have insurance coverage under a plan in which we do not participate, you will be treated as a self-pay patient and FULL payment is due at the time of service.
• Referrals and Pre-authorizations: It is your responsibility to check with your insurance regarding referrals/pre-authorization BEFORE your appointment. If your insurance does not pay because you did not obtain the referral/pre-authorization, you will be responsible for the full amount due.
• Returned Checks: The charge for returned checks is currently $20.00 and will be billed to your account.
• No show/ Late cancellations: Cancellation of office appointments (excluding shot appointments) are required at least 24 hours prior to the appointment. A charge of $50.00 for missed or late-canceled appointments for existing patients will be billed to your account. A charge of $100 dollars will be assessed for missed or late-canceled appointments for new patients. This charge is not covered by insurance and must be paid before any further appointments can be scheduled.
• Past due accounts: If you have a balance that is past due, this balance must be paid in full prior to scheduling your next appointment. Payment plans can be arranged by contacting our billing department. If your account becomes past due, we will take necessary steps to collect this debt. Collection of debts may be made by referring debts to a collection agency, an attorney or court. You agree to pay all charges that we incur in collection of this account, including court costs and attorneys’ fees.
• Waiver of Confidentiality: You understand if this account is submitted to an attorney or collection agency and/or if we have to litigate in court, the fact that you received treatment at our office may become a matter of public record.
• Divorce: In case of divorce or separation, the patient is responsible for payment of the account. If the divorce decree requires the other party to pay all or part of the treatment costs or to carry insurance for the patient, we will file the insurance if the information is provided to us. However, it is the responsibility of the patient to pay all balances due and to collect unpaid amounts from the other party.
• Minor Children of Divorced Parents: After a divorce or separation, both parents are responsible for those charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent. It is also the responsibility of the authorizing parent to provide accurate billing and employment information on the responsible parent.
• Adults 18-26 years old: In initialing this paragraph, you certify that you are the adult who is responsible for payment of all charges for services rendered. However, you listed your parent’s insurance as your insurer. This insurer will be billed for the charges for the services rendered but you are responsible for all balances and co-pays.
• Adults 18-26 years old: In initialing this paragraph, you specifically authorize us to disclose your Protected Health Information to your parent(s) as the subscriber of your health insurance policy in order to expedite payment of your account. You have the right to revoke this authorization, in writing, by sending such written notification to this office. You understand that we are not responsible for consequences of the disclosure of information which may have been disclosed prior to the date of the revocation.