Statement of Financial Responsibility
& Assignment of Benefits
Thank you for choosing Care on Location, PC (“Care on Location”, “Company”, “Practice”, “we”, “us”, “our”) for your healthcare needs. The services you seek imply an obligation on your part to ensure payment in full is made for services received. This Statement of Financial Responsibility & Assignment of Benefits (“Statement”) will assist you in understanding that financial responsibility. If someone else (parent, spouse, other authorized representative) is financially responsible for your expenses or carries your insurance, please share this Statement with them, as it explains our practices regarding forms of accepted payment, insurance billing, co-payments, co-insurance, and patient billing.
Authorization to Process Claims & Release of Information
You authorize CARE ON LOCATION and the clinicians, providers, professionals, care givers and/or professional corporations that render services to you to process claims for payment by your insurance carrier on your behalf for covered services provided to you by the Company. You authorize the release of necessary information, including medical information, regarding medical services rendered during this consultation and treatment or any related services or claim, to your insurance carrier(s), including any managed care plan or other payor, past and/or present employer(s), Medicare, CHAMPUS/TRICARE, authorized private review entities and/or utilization review entitles acting on behalf of such insurance carrier(s), payers, managed care plans and/or employer(s), the billing agents and collection agents or attorneys of the Company and/or the independent contractor physicians, care givers, and / or professional corporations, your employers Workers Compensation carrier, and, as applicable, the Social Security Administration, the Health Care Financing Administration, the Peer Review Organization acting on behalf of the federal government and/or any other federal or state agency for the purposes(s) of satisfying charges billed and/or facilitating utilization review and/or otherwise complying with the obligations of state or federal law. Authorization is hereby granted to release health record data and/or copies to your attending and/or admitting healthcare professional and/or any consulting healthcare professional and/or any healthcare professional you may be referred to for follow up care. You further authorize the Company and any other healthcare provider or professional rendering services to you to obtain from any source medical history, examinations, diagnoses, treatments and other health or insurance authorization information for the purpose(s) of satisfying charges billed and/or facilitating utilization review, providing medical treatment and/or the evaluation of such treatment, and/or otherwise complying with the obligations of federal law. A photocopy of this Authorization may be honored.
Medicare Patient’s Certification, Authorization to Release Information, Request
You certify that the information given by you in applying for payment under Title XVIII of the Social Security Act is correct.You authorize any holder of medical or other information about you to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a RELATED Medicare claim. You request that payment of authorized benefits be made on your behalf.
- You are ultimately responsible for all payment obligations arising out of your treatment or care and guarantee payment for these services. You are responsible for deductibles, co-payments, co-insurance amounts or any other patient responsibility indicated by your insurance carrier.
- Except where prohibited by law, you understand and acknowledge that this assignment does not relieve you of your financial responsibility for all Care on Location charges and treating Clinician charges incurred by you or anyone on your behalf, and you hereby accept such responsibility, including but not limited to payment of those fees and charges not directly reimbursed to the Company and treating Clinicians by any Benefit plan or program. Furthermore, you agree to pay all costs of collection, reasonable attorneys’ fees and court costs incurred in enforcing this payment obligation.
- Knowledge of what your insurance does or does not cover and its associated co-pays, co-insurance, restrictions, need for referrals or pre-approvals ultimately rests with you, the healthcare consumer. Please read your policy details before engaging in services with our Company.
- Balances may be paid via credit or debit card. We may also employ other electronic methodology of accepting cash equivalents such as wire transfers, and ACH transfers.
- You will be considered Direct Pay under the following circumstances
- You are covered by an insurance plan that our Company and/or providers do not participate in.
- You do not have current and valid insurance card information at the time of requesting services from our Company.
- You do not have health insurance coverage
- Care on Location, PC requires payment in full at the time service is rendered.
- Initial costs to request services from our Company are listed on our website. An estimate of additional costs for treatments and procedures performed can be relayed to you verbally at the time of service prior to performing said treatments and procedures. You have the right to refuse recommended treatment and procedures at the time of service.
By acknowledging this Statement, you agree to all of the terms above.
Cancellation & Refund Policy
- For Telemedicine Care Consults (video visits), including Assisted Telemedicine Care Consults
- You (or your “authorized representative) may cancel your visit at no charge to you from the time service is requested up until the point where a provider has been assigned to you;
- Once a provider has been assigned to you and up until the point where you engage in the actual video call with the provider, should you choose to cancel the visit, you will be charged one-half of the listed cash price at the time of cancellation for either the Telemedicine Care Consult or the Assisted Telemedicine Care Consult, depending on which one for which you had requested service.
- After you have begun the telemedicine care consult and the video interaction with the provider has started, should you decide to discontinue the interaction by either verbalizing that you wish to discontinue or by intentionally ending the meeting, there will be a full charge for the visit equivalent to the cash price for a Telemedicine Care Consult or Assisted Telemedicine Care Consult, depending on which one you had requested service for.
B. For On Location Care Consults (in-person, “house call” visits)
- You may cancel your visit at no charge to you from the time you are placed in the “Virtual Waiting Room” (also know as the “Care Queue”) up until the point where a provider has been assigned to you.
- Once a provider has been assigned to you and up until the point where the provider begins the commute to your location, should you choose to cancel the visit, you will be charged one-half of the listed cash price at the time of cancellation for the “trip charge” for an On Location Care Consult.
- Once a provider has begun the commute to your location, should you decide to cancel the visit, there will be a full charge for the visit equivalent to the listed cash price at the time of cancellation for the “trip charge” for an On Location Care Consult.
- If you are not at the location specified by you, the provider cannot gain access to your location, or if the provider is unable to reach you by phone or video to confirm your location, there will be a full charge for the visit equivalent to the listed cash price at the time of the occurrence for the “trip charge” for an On Location Care Consult.
- For ALL Consults
- Once a medical evaluation has been performed and/or medical advice has been dispensed, the visit is considered complete and the visit charge is considered finalized.
- There will be no refunds based on a provider not prescribing a requested medication or a medication that you feel should have been prescribed as a result of the consultation. All prescriptions are at the sole discretion of the evaluating provider.
- Partial to Full refunds will be considered for cases where failure to complete the consult has been found to be the result of an action on the part of Care on Location providers and/or staff.
- Any refunds that are provided are at the discretion of the provider and Care on Location management as well as any applicable state or federal laws.
By acknowledging this Statement, you agree to all of the terms above.