Get Well Now is committed to serving our patients with professionalism and caring and from our patients, we expect the same commitment. This includes being on time for your appointment and calling to cancel an appointment if you can’t make it. It also includes financial responsibility, like presenting your identification and insurance cards at every appointment and making your
copay and deductible payments at the time of your office visit with cash, check or credit card.
Your responsibility is to provide us with accurate and complete information concerning your primary and secondary insurance medical benefits, including referral documents from other providers. Current identification and insurance benefit cards are to be presented at each office visit. As a courtesy, Get Well Now will file your insurance claim for you. If you are a Medicare patient, we will bill Medicare and your secondary insurance for you.
For services outside of our clinic, like radiology, laboratory, surgery centers, physical therapy, hospitals, and rehabilitation centers, it is your responsibility to know which facility you are required to use. If you aren’t sure, please talk to your insurance member services or one of our staff before scheduling.
For insured patients: I authorize payment to be made on my behalf to Get Well Now for any services provided to me by my provider. I authorize my provider to release to the Get Well Now and its agents any information needed to determine my benefits.
I understand that my signature requests payment be made to pay my claim. My signature also authorizes the release of medical information necessary to pay my claim. My signature also authorizes the release of benefits payable and medical information necessary to pay any secondary insurance payer.
This is a legally binding contract between Get Well Now and you. The words, I, me, my, you and your all refer to the patient. I agree to be financially responsible for payment of Get Well Nows services. Cash, check or credit cards are acceptable forms of payment for these services.
Current insurance cards must be presented at every office visit. Get Well Now is not responsible for filing your insurance claim, but as a courtesy, we will do so. I agree to pay the remaining balance after my insurance has paid on my claim immediately upon receipt of a statement.
I agree to give Get Well Now my complete and accurate insurance information for primary and secondary insurance benefits including referral documents from other providers, if needed. I understand that if I fail to give complete and accurate information about my insurance benefits this may result in a denial of my claim or a delay in payment. I agree to pay Get Well Now the balance on my account after my insurance claim has been processed.
I agree that if my insurance benefit requires me to provide a referral and if the referral is not in place before my appointment, that I will pay in advance an estimate of charges for my office visit or reschedule my appointment.
I understand that I will be responsible for any missed appointments or any canceled appointments in which a 24-hour notice was not given. There will be a fee of $30.00 for any missed office visits and $50.00 for any missed office procedures.
I understand there will be a $25.00 fee for all returned Checks
I understand that all services provided to me by Get Well Now are considered medically necessary, if I fail to have a procedure performed or do not comply with my provider’s instructions it may be against medical advice and may void my insurance benefits. Should this occur, I agree to pay the balance remaining on my account after my insurance has been processed.
I understand that my insurance may or may not agree to the usual, customary or reasonable charges for my local area. I understand that my benefits may not cover all services or might deny payment for services that have been approved of in advance. I agree to pay the balance remaining on my account after insurance has been processed.
If I have a high deductible policy or do not currently have insurance benefits, I agree to pay an estimate of charges for my office visit in advance and understand that other charges may apply.
Get Well Now has a contract with my insurance company. Get Well Now will receive payments from my insurance company for covered services provided by my insurance benefits. I agree to pay co-payments and deductibles at the time of service. If co-payments are not made at the time of service, I understand that my appointment may be rescheduled.
I agree to pay any balance remaining on my account for any reason upon receipt of a statement and I understand that when requested, I must give Get Well Now my current address and other contact information. I understand that if I fail to pay the balance on my account this may result in Get Well Now pursuing any collection means possible.
If my account becomes delinquent, it may be forwarded to an outside collection agency without notice. If this happens, I will be responsible for all costs of collection, including but not limited to interest, rebilling fees, court costs, attorney fees, and collection agency costs.
If the reason for my appointment is related to a work injury or auto accident, I agree to give Get Well Now the case number or policy number, the workman’s compensation or insurance carrier’s name, address or other contact information at the time of my appointment so that Get Well Now can bill workman’s compensation or the auto insurance carrier for my visit. If I do not provide this information at the time of the visit, I agree to pay all charges for my visit.
I hereby authorize direct payment of medical benefits, including medical benefits to which I am entitled to Get Well Now. This is a DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS. This authorization will remain in effect until canceled by me in writing. A copy of this authorization is as valid as the original document. I authorize the release of any medical information necessary to obtain payment and I understand that I am financially responsible for all charges, late fees, interest, attorney fees, and collection charges considered patient responsibility by my insurance company. I understand that if I am not insured I am responsible for the charges of all services provided to me. I authorize Get Well Now to deposit checks received on my account when made out in my name. I have read and I understand Get Well Now’s financial policies and I accept responsibility for the payment of any fees associated with my care.
