Payment and Card on file
Children’s Urgent Care Managed Care Service Release/ Card on file payment
I authorize treatment by Children’s Urgent Care(CUC) for the reason that I presented at CUC I understand that if appropriate, CUC will bill my Health Plan for services to be rendered. However, I also understand that pursuant to Maryland law, ExpressCare is authorized to bill me under the following conditions:
I. When I choose to receive services covered under my benefit plan without a referral and/or authorization from my Health Plan, I understand that my Health Plan may require that I get a signed referral from my primary care physician and/or authorization from my Health Plan to receive covered services. If my Health Plan determines that I did not get a referral and/or authorization when I should have, I understand that I am responsible for payment for the services rendered.
II. When I receive services that are not covered under my benefit plan, and if my Health Plan decides that the services I receive are not covered under my benefit policy, I understand that I will be responsible for payment for the services rendered. This includes Telemedicine visits.
III. When I receive any type of testing after being triaged at Children’s Urgent Care and I then elect to leave prior to being seen by a Provider, I will be responsible for paying out of pocket for those tests that were performed. These charges will be paid prior to leaving the center.
Children’s Urgent Care Centers submit claims to insurance carriers as a convenience to all of our patients. Due to rising nonpayment of bills, we request authorization to bill a major credit card or debit card to cover amounts determined by your insurance company to be your responsibility. We recommend using a credit card.
Upon receipt of an explanation of benefits from your insurance carrier any unpaid portion of your claim will be billed, in accordance with your insurance carrier’s determination of “Patient Responsibility”, to your credit card or debit card automatically. Please note that the timing of this transaction is determined by your insurance company. ExpressCare may be able to send an email prior to this transaction. We advise having funds available for 1 year from today’s date of service. In the event your insurance pays your visit in full, your card will not be charged.
All patients that have a deductible plan with a remaining deductible balance, must either provide a credit card to be stored in Vantiv for any fees not paid by insurance company, OR pay the required deductible fee prior to visit. <p
All credit/debit card information will remain absolutely confidential and securely stored by Vantiv. Children’sUrgent Care Centers will not store any banking account data.</p
I hereby authorize Children’s Urgent Care Centers to charge any and all outstanding balances, up to $300.00 after insurance company reimbursement or denial, to my credit/debit card. I understand that I will not receive a statement if there is no balance due after processing my credit/debit card for payment.
I acknowledge receipt of the Children’s Urgent Care Managed Care Service Release.
Signature:_______________________________ Date:__________________ (patient/parent/conservator/guardian)
I agree to be responsible for all charges not otherwise paid by third-party insurance. I understand that I am fully responsible for charges incurred for medical services received, which charges I expressly agree are reasonable. In the event that my account is referred to any attorney for collection, I agree to be responsible for and to pay my bill and all court cost, private process fees, and other cost of collection as well as attorney’s fees in the amount of 20% of my bill, which sum I expressly agree is reasonable. In the event that my check is return unpaid for any reason whatsoever, I agree to pay in addition to the amount of the check the greater of twice the amount of the check plus a $35.00 administrative charge or the maximum amount allowed by law. I acknowledge that this sum is a reasonable amount to compensate Children’s Urgent Care for the costs incurred by the issuance of any returned check. I understand that this is an agreement under seal and subject to a twelve statute of limitations.
I acknowledge receipt of the Children’s Urgent Care Center’s Payment Policy.
Signature: _______________________________ Date: __________________ (patient/parent/conservator/guardian)