Patient Responsibility. The cost of Medicaid facility-based services not paid for by the Medicaid program, for which the enrollee is responsible. Patient responsibility is the amount enrollees must contribute toward the cost of their care. This is determined by the Department of Children and Families’ Economic Self Sufficiency only and is based on income and type of placement.
Patient Responsibility. It is the Patient’s responsibility to advise each and every attorney of the existence of this agreement. Further the Patient must advise the above named Medical Provider at reasonable intervals the status of the legal case. It is also the Patient’s responsibility to advise the Medical Provider within 5 days of legal matter collecting any funds and to request a xxxx for any and all outstanding charges. The Patient hereby directs their present attorney and any future attorney to advise the Medical Provider, as soon as possible, about any funds related to the accident case becoming available to the above named Patient. Further, if the legal action fails to fully pay the Medical Provider’s outstanding balance(s) then the remaining amounts are to be paid by the Patient. The Medical Provider may, at his/her discretion at any time, xxxx any third party payer or government payer.
Patient Responsibility. The amount Members must contribute toward the cost of their care. United shall utilize Patient Responsibility as calculated by the Department of Children and Families (DCF) for each enrollee, in compliance with 42 CFR 435.622 and 435.725. As applicable, Provider is responsible for collecting Patient Responsibility from Member. SECTION 5 UNITED REQUIREMENTS
Patient Responsibility. All copays, coinsurance, and self-pay balances are due at the time of service. Insurance and personal information provided must be accurate and up to date. You may pay with cash, credit card or check made payable to: Catalyst PT & Wellness at the time of visit. Missed appointments or cancellations less than 24 hours will be charged 50% of any wellness or non-physical therapy service, and $40 for physical therapy. A $25 fee will be charged for any returned check unpaid by your financial institution. I certify I am 18 years of age and/or the legal guardian/guarantor. I understand and accept full financial responsibility for the patient listed below. Printed Name of Patient Date Signature of Patient and/or Legal Guardian Insurance The cost of your services may be covered by your insurance provider. As a courtesy, our office may verify your benefits in advance, however it is also your responsibility to verify your physical therapy benefits before the time of service. Patient Name Subscriber Name Primary Insurance Secondary Insurance Insurance Company Insurance Company Policy # Policy # Group #/Claim Group #/Claim # Phone Phone # Claims Address Claims Address City State Zip City State Zip Insured Name Insured Name Relationship to Patient Relationship to Patient Employer Employer Soc. Sec D.O.B. Soc. Sec. D.O.B.
Patient Responsibility. The amount an enrollee must pay towards Medicaid services after personal, unreimbursed medical expenses, community spouse allowances, and income placed in a qualified income trust are accounted for. The patient responsibility calculation is performed by DCF’s ACCESS unit and is detailed on the enrollee’s Notice of Action which details the Medicaid eligibility period and the amount of patient responsibility due monthly.
Patient Responsibility. Before every visit for an in-office procedure, diagnostic testing and surgery, we will estimate your patient responsibility (deductible and/or co-insurance) as determined by your contract with your insurance carrier. You will be informed of any such costs PRIOR to your visit and we expect these payments at time of service. Many insurance companies have additional stipulations that may affect your coverage. You are responsible for any amounts not covered by your insurer. If your insurance denies any part of your claim, or if you or your physician elects to continue past your approved period, you will be responsible for your balance in full. Finance charges will begin to accrue on any unpaid patient responsibility balance after 90 days old. REFERRALS: If your insurance policy requires a referral, you are responsible for making sure that there is a current and valid referral prior to being seen. Please contact your Primary Care Physician’s office prior to your appointment to obtain your referral.
Patient Responsibility. PROVIDER shall bill and collect all Copayments and Deductibles specifically permitted in a Participant’s benefit plan from the Participant. PROVIDER shall further bill and collect all charges from a Participant for those non-Covered Services provided to a Participant. Provider may bill a Medicaid or Medicare Participant for a non-compensable service or item, if the recipient is told by Provider in writing, before the service is rendered, that it is not covered by the Medicaid or Medicare program. Under no circumstances shall the Provider bill any Participant, except for authorized co- payments, deductibles, or co-insurances, for services authorized by Xxxxx or Plans or covered under this Agreement. Plan Participants participating in the PA Medical Assistance MCO program are under no circumstances to be charged a co-payment. Provider shall provider services to Medicaid consumers who have selected Plan, but whose coverage is not yet effective. Services for these Medicaid consumers should be invoiced to Pennsylvania (PA) Medical Assistance MCO Program on a fee-for-service basis. To the extent permitted by law, PROVIDER shall provide a courtesy discount of twenty percent (20%) off PROVIDER’s usual and customary fees to Participant(s) for the purchase of materials not covered by a Plan.
Patient Responsibility. The amount an enrollee must pay towards Medicaid services after personal, unreimbursed medical expenses, community spouse allowances, and income placed in a qualified income trust are accounted for. The patient responsibility calculation is performed by DCF's ACCESS unit and is detailed on the enrollee's Notice of Action which details the Medicaid eligibility period and the amount of patient responsibility due monthly. PDO Pre-Screening Tool ILTC Plans Only) – The required screening tool to be used by the case manager. in assisting prospective participants and prospective representatives to determine whether they are willing and able to participate in the PDO. .
Patient Responsibility. Facility will retain responsibility for the care of patients and will maintain administrative and professional supervision of students insofar as their presence affects the operation of Facility and/or patient care.
Patient Responsibility. All copays, coinsurance, and self-pay balances are due at the time of service. • Insurance and personal information provided must be accurate and up to date. • You may pay with cash, credit card or check made payable to: Catalyst PT & Wellness at the time of visit. • Missed appointments or cancellations less than 24 hours will be charged at 50% of service cost for all non-PT services, and $45 for physical therapy. Your payment information will be stored at your initial visit so that these charges can occur automatically. • A $25 fee will be charged for any returned check unpaid by your financial institution. I certify I am 18 years of age and/or the legal guardian/guarantor. I understand and accept full financial responsibility for the patient listed below. Printed Name of Patient Date Signature of Patient and/or Legal Guardian Insurance The cost of your services may be covered by your insurance provider. As a courtesy, our office may verify your benefits in advance, however it is also your responsibility to verify your physical therapy benefits before the time of service. Patient Name Subscriber Name Primary Insurance Insurance Company Policy # Group #/Claim Phone Claims Address City State Zip Insured Name Relationship to Patient Employer Soc. Sec D.O.B. Secondary Insurance Insurance Company Policy # Group #/Claim # Phone Claims Address City State Zip Insured Name Relationship to Patient Employer Soc. Sec. D.O.B.
