Financial Responsibility Agreement
Effective Date: 06/06/2023
This Financial Responsibility Agreement (the “Agreement”) sets forth the terms and conditions regarding the financial responsibility for services provided by Credence Home Health Services (“we,” “us,” or “our”). By receiving our services, you agree to the following terms:
1. Financial Responsibility
1.1 Payment Obligation: You acknowledge and agree that you are responsible for the payment of all charges and fees associated with the services provided by Credence Home Health Services. This includes but is not limited to, charges for medical services, supplies, medications, and any other related expenses.
1.2 Insurance Coverage: If you have health insurance coverage, you authorize us to bill your insurance provider directly for the services rendered. However, you understand and agree that you are ultimately responsible for any outstanding balances not covered or reimbursed by your insurance company. It is your responsibility to provide accurate and up-to-date insurance information to ensure proper billing.
1.3 Non-Covered Services: Some services may not be covered by your insurance plan. In such cases, you are responsible for the full payment of those services. We will inform you in advance if any services are not covered by your insurance and provide an estimate of the associated costs.
1.4 Co-Payments and Deductibles: If your insurance plan requires co-payments, deductibles, or any other out-of-pocket expenses, you agree to make those payments promptly as specified by your insurance plan or as billed by us.
2. Billing and Payment
2.1 Invoicing and Statements: We will provide you with regular invoices or statements that outline the charges for the services provided. These invoices or statements will indicate the amount due, the payment due date, and any outstanding balances.
2.2 Payment Methods: You agree to make payments in the form of cash, check, credit card, or any other payment method accepted by us. Payments are due by the specified due date unless alternative payment arrangements have been made in writing.
2.3 Late Payments: Late payments may be subject to late fees or interest charges as permitted by applicable laws. Failure to make timely payments may result in the suspension of services or referral to a collection agency. You agree to be responsible for any collection costs incurred by us to collect outstanding balances.
3. Financial Assistance and Appeals
3.1 Financial Assistance: If you are experiencing financial hardship and are unable to pay for the services provided, we encourage you to contact our billing department. We may have financial assistance programs or alternative payment arrangements available to eligible individuals.
3.2 Appeals and Disputes: If you disagree with any charges or have questions regarding your invoice or statement, you must notify us promptly. We will work with you to address any disputes or concerns and provide explanations or assistance as necessary.
4. Confidentiality and Authorization
4.1 Personal Information: You understand and agree that we may collect, use, and disclose your personal information as necessary for billing and payment purposes. We will handle your personal information in accordance with applicable privacy laws and our Privacy Policy.
4.2 Insurance Authorization: By signing this Agreement, you authorize us to release any medical or other information necessary for billing and payment purposes to your insurance company or other third-party payers.
5. Governing Law and Jurisdiction
This Agreement shall be governed by and construed in accordance with the laws of Dallas, TX. Any disputes arising from this Agreement shall be subject to the exclusive jurisdiction of the courts located in Dallas, TX.
Please read this Agreement carefully. By signing below, you acknowledge that you have read, understood, and agree to the terms and conditions set forth in this Financial Responsibility Agreement.
Patient/Responsible Party Name: __________________________
Signature: _____________________________