Occupational Medicine Contract

First Name*:
Last Name*:
Email*:
Company Name*:
Phone*:
Address*:
City*:
State/Province*:
ZIP/Postal Code*:
Question/
Comments:
File Upload:
Direct Employee Representative (DER) * :
email for drug screen results/ billing/ * :
Number of Employees * :
DOT Urine Drug Screen (with MRO review) * :
5 Panel UDS with company MRO :
Consortium :
Workers Compensation-Billed to Carrier :
Pre-Employment/ Medical Entrance Physical Exam :
Blood Pressure Check :
5 Panel UDS in house (confirmation on positives) :
6 panel Urine Drug Screen rapid testing :
10 panel Urine Drug Screen (in house, with confirmation on positives) :
Spriometry :
Audiometry :
Venipuncture :
Hepatitis B series :
Hepatitis B titre :
MMR titires :
Tetanus Vaccine :
Tuberculosis skin test (PPD) :
Influenza Vaccine (Subject to Market Availability) :
Chest Xray :
HIV with Confirmation on Positives (Western Blot) :
Varicella-Zoster V ab, IgG :
Hepatitis C virus Antibody :
Hepatitis B surface AG Screening :
Hepatitis B surface Antibody Screening :
RPR (syphillis) :
Hepatitis :
Hemoglobin A1C :
Hearing Conservation :
Breath Alcohol Testing :
Lipid Panel (Total Cholesterol, LDL, HDL) :
Electrocardiogram (EKG) :
Categories Close
Click a category to view the category locations
All
Ambient Care Seaford
Locations:

 

 

 

PATIENT FINANCIAL RESPONSIBILITY STATEMENT

 

Thank you for choosing Ambient Medical Care LLC as your healthcare  provider.  The medical services you seek imply an obligation on your part to ensure payment in full is made for services received. This Patient Financial Responsibility Statement (“Statement”) will assist you in understanding that financial responsibility. Feel free to ask if you have any questions. If someone else (parent, spouse, domestic partner, etc.) is financially responsible for your expenses or carries your insurance, please share this Statement with them, as it explains our practices regarding insurance billing, copayments, and patient billing. By your acknowledgement of this Statement and/or by receipt of medical services from Ambient Medical Care LLC, (“Medical Associates”), you agree:

 

  1. You acknowledge and agree to all FINANCIAL POLICIES of Medical Associates, including those policies available online at www.ambientmedicalcare.com. Questions about these policies may be addressed to the Patient Accounts Staff. These policies may be changed from time to time by Medical Associates, without notice.
  2. You are ultimately responsible for all payment obligations arising out of your treatment or care and guarantee payment for these services. You are responsible for deductibles, co-payments, co- insurance amounts or any other patient responsibility indicated by your insurance carrier or our FINANCIAL POLICIES, which are not otherwise covered by supplemental insurance.

 

  1. You are responsible for knowing your insurance policy. For example, you will be responsible for any charges if any of the following apply: (i) your health plan requires prior authorization or referral by a primary care physician (PCP) before receiving services at Medical Associates, and you have not obtained such an authorization or referral; (ii) you receive services in excess of such authorization or referral; (iii) your health plan determines that the services you received at Medical Associates are not medically necessary and/or not covered by your insurance plan; (iv) your health plan coverage has lapsed or expired at the time you receive services at Medical Associates; or (v) you have chosen not to use your health plan coverage. If you are not familiar with your plan coverage, we recommend you contact your carrier or plan provider directly.

 

  1. You will be required to follow all registration procedures, which may include updating or verifying personal information, presenting verification of current insurance, and paying any co-pays or other patient responsibility amount at each visit. Your card or other insurance verification must be on file for your insurance to be billed. If we do not have your card on file, or are unable to verify your eligibility for benefits, you will be considered a self-pay patient. As a self-pay patient, our fee  is expected to be paid in full at the time of service. If the insurance card or other necessary information is furnished after the visit, we may file a claim with your insurance; and, if paid in full by your insurance, you will be reimbursed. If you are not prepared to make your co-pay or other patient responsibility amount, your visit may be rescheduled by Medical Associates.

 

5.              We may verify your insurance benefits or submit your claim to your insurance carrier as a courtesy to you. You agree to facilitate payment of claims by contacting your insurance carrier when necessary.  Without waiving any obligation to pay, you assign to Medical Associates, for application onto

 

your bill for services, all of your rights and claims for the medical benefits to which you, or your dependents are entitled, under any  federal or state healthcare plan (including, but not limited to, Medicare or Medicaid), insurance policy, any managed care arrangement or other similar third-party payor arrangement that covers health care costs and for which payment may be available to cover the cost of the services provided to you. You authorize Medical Associates and associated physicians, staff, and hospitals to release patient information acquired in the course of your examination and/or treatment including but not limited to any and all medical records, notes, test results, x-ray reports, MRI reports or other documents related to your treatment (including itemization of any charges and payments on my account) that is deemed necessary to process this claim to the necessary insurance companies, third party payors, and/or other physicians or health care entities as they require to participate in your care. It is important to notify us as soon as possible of any changes related to your insurance coverage. Failing to do so may result in unpaid claims, and you will be responsible for the balance of the claim. Medical Associates does not accept responsibility for incorrect information given by you or your insurance carrier regarding your insurance benefits or benefit plans.

 

  1. If your insurance carrier does not remit timely payment on your claim, you will be responsible for payment of the charges within the terms set forth herein. Once your insurance carrier processes your claim, we will bill you for any remaining patient responsibility deemed by your insurance carrier. If any payment is made directly to you for services billed by us, you agree to promptly submit same to Medical Associates until your patient account is paid in full. If you make a payment that results in a surplus on your account, you authorize Medical Associates to apply the overpayment to any other account for which you are financially responsible, including your account, a member of your family’s or dependent’s account, or on any account for which you are a financially responsible party, and any remaining balance will be returned to the payor.

 

  1. You will be mailed a billing statement that contains the total cost of your service(s) or procedure(s) received during your visit(s). You may generally expect this billing statement within twenty

(20) days after your insurance company has responded to a submitted claim. You must notify us of any errors or objections to the billing statement within thirty (30) days or they will be deemed accurate, and the fees and expenses shall be deemed reasonable and necessary for the services incurred. If there is a problem with your account, it is your responsibility to contact the Patient Accounts Staff to address the problem or to discuss a workable solution.

 

8.              Whether or not you have insurance or are self-pay, payment of any account balance is due at our Patients Account Offices in Dubuque, Iowa, within thirty (30) days of receipt of your billing statement. If you need to  make special arrangements for payment, you may contact our Patient Accounts Staff to determine if you are eligible for a mutually agreeable alternative payment plan. Partial payments may be accepted and applied, without waiver, at the discretion of Medical Associates. Acceptance of any partial payment shall not extend any time period, cure any default, or be deemed to satisfy any remaining balance due. If any balance on your account is over thirty (30) days past due, your account will be in default and may be referred to a collection agency. The balance of any account not paid within ninety (90) days will begin to accrue interest at the rate of 1.5% per month or the maximum allowed by applicable law, whichever is lower. For small balances, between $4.01 to $25.00, we may stop sending billing statements any time after the initial statement, but you understand that the amount shall remain due and owing until paid in full.

 

  1. We accept payment by check, cash, money order, debit cards or credit cards (Visa, MasterCard or Discover).

 

a.              Payment by Check. If payment is made by check and it is returned or declined for any reason, your account will be charged a surcharge of $20.00 or up to the applicable state maximum legal limits, whichever is lower, in addition to any costs assessed or charged by any depository institution. When you pay by check you also authorize Medical Associates, if your check is dishonored or returned for any reason, to electronically debit your account for the amount of the check plus a processing fee of up to the state maximum legal limits (plus any applicable sales tax). PLEASE NOTE: The above language authorizes an electronic debit to your account for the amount of the check plus the state-allowed recovery fee. In accordance with the rules of the National Automated Clearing House Association, this authorization is to remain in effect until Medical Associates has received written notice of termination in such time and in such manner to afford us a reasonable opportunity to act on it. This does not, however, mean that Medical Associates cannot collect a returned check fee by other methods.

 

b.              Payment by Credit Card/Credit Card on File. When you pay by credit card to be held on file, you agree to keep the credit card information current, and you authorize Medical Associates to securely store your credit card information, and only charge it should you have an outstanding balance or any leftover balance from a processed claim in the future. The storage system used is fully compliant to the highest level of credit card storage security regulations. Once stored, only the last five digits of your credit card are viewable by Medical Associates personnel. You understand that you are responsible for all charges for services that you receive from Medical Associates, and if the patient responsibility portion of your charges (including charges applied to your deductible and/or coinsurance) is not paid in full within thirty (30) days following receipt of the financial responsibility statement, then Medical Associates will bill your stored credit card for the outstanding balance due.

 

  1. Managed Care (HMO, PPO, etc.). All managed care co-payment amounts are due at the time of service. If your insurance plan requires a referral authorization from a primary care physician, you are responsible for presenting this at your initial visit. If you request an office visit without a referral authorization, your insurance plan may deem this as “out of network” or “non-covered” treatment, and you will be responsible for a larger amount or all of the charges. You acknowledge that it is your responsibility to be aware of what services are covered and you agree to pay for any service deemed to be non-covered or not authorized by the plan.

 

11.           Medicare. Medical Associates is a participating provider with the Medicare program  and accepts as payment the Medicare allowable, patient deductible and/or 20% co-insurance. Medicare or secondary carriers do not cover some procedures and supplies. Please make certain you understand which aspects of your treatment are covered before proceeding. You understand that you will be responsible for your annual deductible, the co-payment, and any non-covered services specified by Medicare. We may submit a claim to any supplemental plan as a courtesy to you, so long as you provide all necessary policy information.

 

12.           Medicaid. If you are a Medicaid patient, you must present a valid eligibility card at the time of registration and prior to the time of service. Your eligibility status will be verified monthly. Without verification of coverage, you will be responsible for the entire balance of your account. As a courtesy to you, your account will be billed to Medicaid when we receive all necessary information. You are responsible for non-covered portions and spend down requirements associated with your individual coverage. If at any time you are not eligible for Medicaid coverage and wish to be seen, you will be treated as a self-pay patient and must make payment at the time of service.

 

13.           Workers’ Compensation Cases. Charges for services incurred as a result of a verified work- related injury will be treated as workers’ compensation, and we will bill the workers’ compensation

 

carrier as a courtesy. You must provide necessary information to bill the carrier. You are responsible for the completion of information with the employer and approval of the workers’ compensation claim. In case your workers’ compensation claim is denied, you will also provide us with your medical insurance information.  If your claim is denied, we will bill your regular medical insurance carrier.  When the claim is no longer pending and any portion of your claim is ultimately resolved against you by workers’ compensation and your medical insurance, you will be required to pay all amounts due within thirty (30) days.

 

  1. Third-Party Liability Injuries. If you receive treatment as a result of a third-party liability injury (for example: motor vehicle accidents, premises liability, or other general liability claims against third parties), the balance for services rendered is considered due in full at the time of the service. Because Medical Associates does not protect charges incurred relating to or arising out of third party liability, we will not accept a delay in payment due to settlement disputes and/or litigation. We will not accept a letter of protection from an attorney as a guarantee of payment or assignment of third party insurance payments. Medical Associates cannot act as administrator to resolve financial arrangements. We may agree to bill a third party insurance company of an at-fault party involved in an accident as a courtesy to you. To bill your claim directly, you must provide us all necessary information to confirm coverage for these payments with the auto/third-party carrier. We will also collect information about your personal medical insurance in case the auto/third-party carrier denies your claim. Regardless of whether we submit your claim to third-party insurance, as the patient, you are ultimately responsible for payment.

 

  1. Ancillary Services. You may receive ancillary medical services while a patient of Medical Associates such as: anesthesia, interpretation of tests, neuropsychological testing, imaging services (e.g., x-rays, MRIs) and pathology specimen examination. By signing below, you  understand that some physicians may not provide services in your presence, but are actively involved in the course of diagnosis and treatment. You authorize payment directly for these services under the policy(s) or plan(s) issued to you by your insurance carrier. You may incur additional charges as a result of these ancillary services. You agree to pay all charges due with respect to such services after benefits paid on your behalf by any third-party are credited to your account.

 

  1. Additional Charges. Patients may incur and are responsible for the payment of additional charges at the discretion of Medical Associates including but not limited to: (i) charges for returned checks; (ii) charges for a missed appointment without 24 hours advance notice; (iii) charges for extensive phone consultations and/or after-hours phone calls requiring treatment, or prescriptions; (iv) charges for copying and distribution of patient medical records; (v) charges for extensive forms preparation or completion; or (vi) any costs associated with collection of patient balances, all as allowed by law.

 

17.           Non-Payment on Account. Should collection proceedings or other legal action become necessary to collect an overdue or delinquent account, you understand that Medical Associates has the right to disclose to an outside collection agency or attorney all relevant personal and account information necessary to collect payment for services rendered. You are responsible for all costs of collection including, but not limited to: (i) late fees and charges and interest due as a result of such delinquency; (ii) all court costs and fees (but only to the extent allowed by law); and (iii) a collection fee to be charged under separate agreement with a third-party collections agency, either as a flat fee or computed as a percentage of the total balance due up to the maximum allowed by applicable law, and to be added to the outstanding balance due and owing at the time of the referral to the third party collection agency.  You acknowledge that any such interest assessed on the account will be a late fee as a result of default or delinquency on your account, and is not deemed interest as part of a credit

 

transaction. If your account is referred to a collection agency, attorney, court, or the past due status is reported to a credit reporting agency, it may have an adverse effect on your credit history; and related portions of your account, including the fact that you received treatment at our offices, may become a matter of public record. Failure to  comply with any of these policies may also result in a Credit Withdrawal of Care.

 

  1. Minor Patients. The parent/guardian of a minor is responsible for payment of the minor’s account balance. A minor who is not accompanied by a parent/guardian will be denied any non- emergency treatment unless charges for the treatment have been pre-authorized. Responsibility for payment of treatment of minor children, whose parents are divorced, rests with both parents. Any court-ordered responsibility judgment must be determined between the individuals involved, without the inclusion of Medical Associates.

 

  1. Authorization to Contact. You authorize Medical Associates personnel to communicate by mail, answering machine messages, and/or e-mail according to the information provided in your patient registration information. Medical Associates, or any agent or servicer of your patient account, may use any information you have provided, including contact information, e-mail addresses, cell phone numbers, and landline numbers, to contact you for purposes related to your account, including debt collection. You authorize Medical Associates to use this information in any manner consistent with the information you have provided, including mail, telephone calls, e-mails, or text messages. You expressly consent to any such contact being made by the most efficient technology available, including automatic dialing/e-mailing or similar equipment, or pre-recorded or other messages, even if you are charged for the contact.

 

  1. Financially Responsible Party. If this or a separate Medical Associates Financial Responsibility Statement is signed by another person, on your account, then that co-signature remains in effect until cancelled in writing. Cancellation in writing shall become effective the date after receipt, and shall apply only to those services and charges thereafter incurred. By signing as a financially responsible party, you hereby guarantee the full and prompt payment to Medical Associates of all indebtedness of patient to Medical Associates, whether now existing or hereafter created (the “Indebtedness”); and you further agree to pay all expenses, legal or otherwise, incurred by Medical Associates in collecting the Indebtedness, in enforcing this guaranty, or in protecting its rights under this guaranty or under any other document evidencing or securing any of the Indebtedness. This guaranty shall be a continuing, absolute and unconditional guaranty, and shall remain in force and effect until any and all said Indebtedness shall be fully paid. There shall be no obligation on the part of Medical Associates at any time to first exhaust its remedies against Patient, any other party, or any other rights before enforcing the obligations of the financially responsible party.