This notice explains our financial policies and your responsibility related to your care and treatment and obtains your authorization to release information for the purposes as described below.
Insurance billing information: We will bill your primary insurance company as a courtesy to you. In order to properly bill your insurance company, we require that you disclose all insurance information including primary and secondary insurance, as well as, any change of insurance information. Failure to provide complete insurance information may result in patient responsibility for the entire bill. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and benefits. If your insurance company is not contracted with us, you agree to pay any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance. If we are out of network for your insurance company and your insurance pays you directly, you are responsible for payment and agree to forward the payment to us immediately.
Patients with no insurance and/or high deductible plans: Please inquire with our Patient Account staff regarding options you have available for discounted services and payment plans.
Monthly statement: If you have a balance on your account, we will send you a monthly statement. All balances are expected to be paid in full upon receipt of this statement. Payments not received within 30 business days of receipt of statement are considered past due and could be subject to late fees or interest penalties. Finance Charges of 6.0% annually will be assessed and added to unpaid balances if the account is not paid in full within 30 days after the initial statement date.
Returned checks: There is a fee of $30.00 for checks returned by the bank. If a returned check is received on your account, you will be required to pay all fees associated with this check.
Past due accounts: If you fail to meet financial obligations agreed upon in this financial policy or other payment arrangements made with Raiter Clinic, Ltd., your outstanding balance will be sent to a collection agency and you will be required to pay the entire amount plus any collection agency fees before being scheduled for any further appointments. Unless we can verify Medicaid coverage, all future services will require a $100.00 deposit until credit is reestablished by paying off bad debt balance.
Consent to Telephone Calls for Financial Communication: By providing us with a cellular telephone number, express consent is given to be contacted by Raiter Clinic and affiliates regarding any debt collection. Calls may incur access fees from your cellular provider.
Waiver of confidentiality: We expect you to understand if this account is submitted to an attorney or collection agency, if we must litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.
Divorce: In the case of a divorce the parent authorizing treatment for a child will be the parent responsible for those subsequent 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.
Release of information: I authorize Raiter Clinic to (1) release my protected health information to insurance companies, government programs, and other parties who are responsible for, or who facilitate, payment of my bill, fraud investigation, care management, or quality improvement which includes behavioral health and chemical dependency information; (2) release my protected health information to e-Prescribing networks to facilitate prescription management; (3) release my protected health information electronically or in any other format to my doctors, other healthcare providers, and anyone else Raiter Clinic believes to be involved in my care and treatment. This includes source documents (such as x-rays). This also includes behavior health and chemical dependency information.