Patient Financial Policy

This is an agreement between AdvancedHEALTH, as creditor, and the Patient/Debtor named on this form and indicated by patient/debtor signature below.

In this agreement the words “you”, “your” and “yours” mean the Patient/Debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words “we”, “us” and “our” refer to AdvancedHEALTH. By executing this agreement, you are agreeing to pay for all services that are rendered.

Effective Date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect. A copy of your signed financial agreement will be provided to you.

HEALTH INSURANCE – It is YOUR responsibility to:

Ensure we have been provided with the most current insurance information relative to filing your claim including insurance card, ID number, employer, birth date and patient address. This information will be located on our patient registration form.

  • Ensure we are contracted with your insurance carrier to receive maximum benefits.

  • Pay your co-payment or patient portion at the time of service.

  • Inform us of any insurance changes made after this signed agreement/date of service. Insurance carriers have specific timely filing guidelines and pre-authorization requirements for certain services. If revised insurance information is not provided to us within your insurances’ timely filing limits, you will be required to pay for services in full. If prior authorization was required for services already received and your claim is denied for lack of authorization, you will be required to pay for services in full.

  • Contact your insurance company if no correspondence is received by you within 45 days of the date of service.

    It is OUR responsibility to:
  • Submit a claim to your health insurance carrier based on the information provided by the patient/debtor at the time of service or as updated information is provided.

Provide your health insurance carrier with information necessary to determine benefits. This may include medical records and/or a copy of your insurance card.

Provide MVA patients a courtesy health insurance claim form for their records upon request.

PAYMENT OPTIONS: Per our contracted agreement with your insurance carrier, we are required to collect your co- payment on the day of service. If you do not have insurance, you are required to pay for treatment at the time of service unless other arrangements have been formally made. A separate self-pay financial agreement will be provided to you. Our office collects all copays plus estimated coinsurance and deductibles at the time of service

We accept the following: Cash Check Credit Card (Visa, MasterCard, Discover, American Express) A twenty-five dollar ($25.00) returned check fee will be assessed to the patient account per incident.

For convenience, payments may be made online at www.ePayItOnline.com. To utilize this service, you will need your account number, access code, and Code ID. This information can be found on the patient statement you will receive reflecting your balance. Patients who no-show may be subject to a no-show fee.

PENDING APPROVALS FOR SERVICES: In the event we are unable to obtain approval for services and you wish to proceed, we will not bill your insurance. Services will be reduced to the in-network insurance allowable amount and will apply to the patient’s responsibility. __________ Initials

Patient and/or Debtor Signature: _________________________________________ Date______/_______/_______