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Thank you for choosing Valley Medical Center, PLLC. We are committed to providing you with the very best medical care we have available. Please understand that payment for this medical care is your responsibility.

The following is a statement of our Financial Policy, which prior to the rendering of any treatment, must be read, agreed to and signed. This Financial Policy applies to all service rendered by the providers, lab, x-ray and any other procedure which the provider(s) may consider or advise in treatment of your case (or legal guardian for patient).

New patients with no insurance coverage or without proof of insurance coverage are expected to pay for their services in full on the date of the service. Existing patients with no insurance coverage are expected to pay a minimum of $100.00 deposit toward their services or if surgery the patient would be required to pay 80% of the surgery estimate. Higher deposits may be required depending on the type of service you are receiving. If payment cannot be made, arrangements must be made with one of our patient services counselors. We accept VISA, Discover and Mastercard credit cards.

Credit may be extended after a review by one of our patient services counselors, if you have a good credit rating. All account balance agreements must be paid in full within four months. Routine monthly payments, as per any agreement, are necessary to continue any credit arrangement.

It is the patient's responsibility to verify their benefits for their particular insurance plan and to make sure all the proper authorizations/referrals have been obtained. Some insurance plans will reduce benefits of the insured if treated by a provider outside of the designated network or if the proper authorizations/referrals have not been obtained. It is your responsibility to tell us in advance if your insurance company requires pre-authorization of procedures. Please keep us informed of insurance changes.

We strive to keep our fees as low as possible while still maintaining excellent quality. However, the costs of providing high-quality medical care are constantly rising and increases to our fees are a reflection of a rise in our costs.
CREDIT AND FINANCE CHARGE POLICY AND AGREEMENT (ALL PATIENTS MUST SIGN)
I understand that I am financially responsible for all charges regardless of third-party involvement. I agree to pay any deductible, co-insurance, co-pay, or any services deemed as "non-covered benefit" by my insurance carrier at the time services are rendered. Payment arrangements may be set up, understanding and accepting that a finance charge (1.5% per month/APR 18%) may be applied. (Medicare patients will not be charged the set up fee or finance charge). If payment arrangements cannot be agreed upon, the amount due will be considered delinquent and may be subject to legal action or assignment to a collection agency. Also, failure to pay delinquent accounts may result in termination of care from Valley Medical Center, PLLC. I hereby agree to pay a service charge of $30.00 for each check or other instrument tendered by me but returned to this facility. In consideration for medical services rendered, I acknowledge that I have received notice of Valley Medical Center Medical Group's Financial Policy and agree to pay for said medical services according to such terms.

 

HIPAA NOTICE OF PRIVACY PRACTICES
Please refer to our HIPAA Notice of Privacy Practices for a complete list of permitted uses and disclosures of your Protected Health Information (PHI). You have the right to review our Notice of Privacy Practices prior to signing this consent form. There may be a revision of our Notice of Privacy Practices since you were last here. If this is the case, please review the current one and sign it. The latest version is always available upon request. You may request to restrict the use or disclosure of your protected health information for treatment, payment or health care operations, however we are not obligated to comply with that request. We will be bound by the restrictions you outline only if we agree to those restrictions. You have a right to revoke your consent in writing at any time, but the revocation will have no effect on any actions we took in reliance on the consent before the revocation.

 

ASSIGNMENT OF BENEFITS/MEDICAL RELEASE/CONSENT FOR TREATMENT (All Patients)
With this form (or a photostatic copy of it) I authorize the release of any medical or other information acquired in the course of my treatment to my insurance carrier, practitioners involved in my care at Valley Medical Center, PLLC and their agencies and to outside providers of my care. I understand that in the release of this information it may be transmitted via voice, hard copy, fax, e-mail, electronic insurance send, phone transmission, or data line transmission. Medical treatment and financial billing information is confidential and re-disclosure is prohibited. I authorize assignment of insurance benefits to be paid directly to Valley Medical Center, PLLC for all medical services rendered. I hereby consent to any medical treatment, lab, x-ray or other procedure, which the providers(s) may consider or advise in treatment of my case (or as legal guardian for patient). This signature represents that I have read and agree to the above policy.

 

MEDICARE PATIENT AGREEMENT (For Medicare Patients Only)
I request that payment of authorized Medicare benefits be made either to me or in my behalf to Valley Medical Center Medical Group, P.A. for any services furnished me by that physician/supplier. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services.



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