Definition of Terms
- Date of Service: The Date of Medical Service is Provided.
- Account Balance: the total amount due.
- Where “Patient” is referred to in the below policies, “Responsible Party” is also included jointly, severally, universally, and unconditionally as a guarantor of liability and co-obligor for performance for all purposes.
Guarantee of Payment
Patient is responsible for the payment of all charges for services rendered to the Patient indicated above.
- It is the Patient’s responsibility to prepay any portion of the physician’s fee that will not be / is not covered by the insurance company. This includes any deductible, coinsurance, or items not covered by Patient’s insurance plan.
- Patient understands that this office will be filing a claim with Patient’s insurance company or other third-party payer as a courtesy only. Under no circumstance, does the filing/disposition of a claim relieve Patient from Patient’s responsibility for the payment of all charges for any services rendered.
- It is Patient’s responsibility to NOTIFY HRPD’s front desk of any changes in Patient’s insurance provider and coverage. It is Patient’s responsibility to disclose Patient’s Primary. Failure to do so will result in a charge for claims resubmission fee or $250.00, whichever is greater.
- All lab services are provided as a courtesy. Lab work, including genetic testing, will be billed by another company. Should Patient receive a bill from the third-party Lab, it is Patient’s responsibility to pay such bill. Self-pay fees DO NOT include lab tests by the third-party provider.
- Patient personally guarantees the payment of all charges for medical services rendered. These include, without limitation, claims filed for Workman’s Compensation and/or claims due to personal injury accidents/illnesses. Patient agrees that this authorization shall be valid for all Dates of Services.
- Patient agrees that if Patient needs to have FMLA form signed by HRPD this activity will result in an additional $25.00 charge.
- If Patient chooses to change doctor and transfer Patient’s records to another office, there will be a $15.00 Transfer of Records fee. Similarly, if a letter must be signed by HRPD, there will be a $15.00 Letter fee.
- It is Patient’s responsibility to cancel any appointments at least 24 hours in advance, otherwise Patient will be charged a $50 cancellation/no show fee. Missing an appointment for long scans (basic, detailed anatomy or echo), will result in a $100 cancellation/no show fee. Upon a second no-show/cancellation occurrence in violation of the foregoing, there will be a $100/$200 charge. After three consecutive no-show occurrences, the practice may elect to terminate its relationship with
Collection of Delinquent Account Terms
Failure to pay Patient’s balance within 30 days from any Date of Service is considered a delinquent account and may result in fees and interest being added to Patient’s account Balance listed below.
- Outstanding patient account balances must be paid in full prior to being seen at scheduled and unscheduled appointment.
- If there a balance on the patient’s account, the funds from Advanced Deposit will be used to cover remaining balance on the account.
- A delinquent account balance that is 30 days past due will accrue interest at rate at the maximum lawful interest rate or 18% per annum, whichever is higher, until paid in full.
- An account that is delinquent with any outstanding balances for 60 days will be forwarded and assigned to a collection agency at the patient’s expense.
- Any delinquent account assigned to any collection agency will be charged a collection fee, which upon assignment becomes the due and owing Account Balance. COLLECTION FEE is 50% of THE BALANCE OWING AS OF THE DATE OF SERVICE AND WILL BE ADDED TO THE OUTSTANDING ACCOUNT BALANCE WITH OR WITHOUT SUIT.
- If litigation is required to collect this account, in addition to any Account Balance, Patient agrees to pay interest as set forth herein, plus all costs associated with such collection activity, including but not limited to all collection agency fees as set forth herein as part of the Account Balance, plus any and all attorney fees, court fees, skip tracing fees and costs in addition to any miscellaneous fees the court or jurisdiction may award. Collection exception and Exemptions: allowed charges under Medicare Title XIX (Texas Medicaid) contracts.
- Patient hereby irrevocably waives, to the fullest extent permitted by applicable law, any and all right to trial by jury in any legal proceeding arising out of or relating to this Agreement or the transactions contemplated hereby.
Returned Checks or Disputed Credit Card Payment
There is a fee of $50.00 for any returned check for insufficient funds. If a credit card payment is disputed and payment is wrongfully charged back from High Risk Pregnancy Doctors by Patient’s credit card company, a $50.00 fee will be added to Patient’s account. These amounts may change at any time.
If Patient’s account becomes delinquent, HRPD may assign this account and/or to release any necessary information to any third-party collection agency. Additionally, if Patient’s account is assigned to any collection agency, Patient hereby authorizes the collection agency the right to report this account as delinquent to all the Credit Bureaus in accordance with applicable state and federal law.