Patient Financial Agreement

Patient's Name:
Date:

IMPORTANT: THIS IS NOT AN APPLICATION FOR CREDIT. It is our office policy and pursuant to Department of Labor Guidelines that we inform you of our patient payment policies.

In consideration of the provision of services to the patient named above, the Patient and/or the Responsible Party understand and agree to the following:

  1. Self Pay Patients: Payment for services provided by our physicians is due in full at the time of service. Any balance that remains unpaid after sixty (60) days from the date services were rendered will be considered “delinquent”, and may be subject to additional collection fees.
  2. Insurance (including Medicare and Medicaid): Your insurance coverage is a private agreement between you and your insurance company. You are responsible for any deductible, coinsurance amount, co-pays (which are due at the time of your appointment), or services deemed to be non- covered, not medically necessary, or pre-existing. As the patient or guarantor of the patient, you are responsible for determining that the physician you see participates with your insurance plan. If your physician does not participate, if you are ineligible for insurance, or have given erroneous or incomplete information, you will be responsible for any outstanding balance. Any balance remaining unpaid after sixty (60) days from the date services were rendered will be considered “delinquent”, and may ultimately be subject to additional collection fees.
  3. Worker’s Compensation: If you sustained an injury at work, you must file a report with your employer so that a claim can be established. Your private insurance company will not assume liability for any work-related injury unless the industrial insurance has denied liability.
  4. Third Party Liability/Auto Insurance: If you have no other health coverage, payment in full is due at the time of service. If you do have other health coverage, we will bill the appropriate insurance as a courtesy to you. However, if we are unable to obtain payment after thirty (30) days, payment for the claim will be your responsibility. We do NOT ACCEPT LIENS. As the patient/responsible party, you are ultimately responsible for payment of your bill. Also, be advised that Utah is a “NO-FAULT” state so you must file a claim with your own auto insurance, not the other party’s. If/when your PIP limit has been reached you will need to provide a copy of your PIP letter and PIP ledger to your health insurance so that they may begin paying claims for any future treatment related to the original accident.
  5. Returned Check Charges: A handling charge of $25.00 will be applied to all returned checks, and the entire amount due will be payable within fifteen days from the date that you are notified by this office. In the event the full amount is not replaced in the allotted time, the account may be forwarded to an outside collection agency.
  6. Collection Agencies and Fees: The Rosenberg Cooley Metcalf Clinic reserves the right to place any delinquent account with an outside collection agency for additional collection efforts. Should this become necessary, a forty percent (40%) collection fee may be added to the principal amount of the balance, in addition to a charge for monthly finance charges of eighteen percent (18%) annually, which may have accrued on any balance over 30 days old. The Patient and/or Responsible Party must pay all costs of collection, including reasonable attorney’s fees if the delinquent balance is referred to an attorney for collection. Please note that under Utah state law, the insured party may also be held liable.
  7. Communication Consent: Patient and/or responsible party consents to receiving and responding to efficient communication methods such as mail, telephone, email and text that may be used by the RCM Clinic and any third parties acting under the authority of the RCM Clinic, including billing and collection companies, to resolve questions regarding goods or services rendered and financial obligations owed. Patient understands that the methods of contact may include using artificial voice or automatic dialing/email/text technologies and that account number and other information that may be considered confidential may be referenced in the message(s).
  8. Binding Agreement: This Agreement shall be binding upon the Patient and/or Responsible Party for all charges incurred by the Patient at the Rosenberg Cooley Metcalf Clinic. No statement made by an employee or agent of the RCM Clinic will contradict, void or nullify this Agreement.

Authorization is hereby given to the Rosenberg-Cooley Clinic to submit my claim directly to my insurance company on my behalf. I understand that by signing this form, my signature is not needed each time a claim is submitted on my behalf. I further authorize my insurance carrier to forward payment directly to my physician at the Rosenberg-Cooley Clinic.

I HEREBY AUTHORIZE ROSENBERG COOLEY METCALF CLINIC TO RELEASE ALL MEDICAL AND BILLING INFORMATION NECESSARY TO SECURE PAYMENT FROM ANY INSURANCE CARRIER, ON MY BEHALF.

I have read and fully understand all of the above conditions, and, upon signing this Agreement, acknowledge that I am fully responsible for all payments, charges, and if necessary, all costs of collection efforts as stated above.

Patient Signature*
PATIENT/RESPONSIBLE PARTY SIGNATURE:
Date:
Relationship of responsible party to patient:
Witness:

Start typing and press Enter to search