The following Authorization, Financial Policy and Procedures are in effect for all NFMD patients, and have been updated as of February 6, 2020.
Assignment of Benefits
I certify that the information I have given to New Frontier Mobile Diagnostics (NFMD) is true and correct to the best of my knowledge.
I promise to pay to NFMD all charges and expenses for services provided to me by NFMD in accordance with its current fees and charges, to the extent that those fees and charges are not covered or paid by my insurance or by another payment source such as Medicare or Medicaid.
I request that payment of authorized benefits under any private or government insurance program that covers me, including the Medicare program, be made on my behalf to NFMD for any services furnished to me by NFMD.
I understand that possession of medical insurance does not relieve me of financial responsibility to NFMD.
I will personally be responsible for all charges for services that are not covered by my insurance carrier.
Consent for Medical Treatment
I consent to treatment as deemed necessary and appropriate by clinical providers of NFMD.
Notice of Privacy Practices
I acknowledge that I have been given a copy of NFMD Notice of Privacy Practices.
NFMD may pursue collection of benefits in my name or in the name of NFMD as my appointed representative and agent.
Credit Card Authorization
The diagnostic practice of NFMD requires keeping a credit or debit card on file as a convenient method of payment for the portion of services and cost sharing due that my insurance company identifies as my financial responsibility. I understand and authorize and request NFMD to charge my credit card for balances due for services rendered that my insurance company identifies as my financial responsibility.
Consent for Use and Disclosure of Health Information for Treatment, Payment, and Operations
I consent to the use and disclosure of my protected health information by NFMD, its staff, and business associates for the purposes of treatment, payment, and health care operations. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services or other third party payer organizations and its agents any information needed to determine my Medicare or health care benefits, if any, for services furnished by NFMD.
My protected health information includes any information that reasonably identifies me and relates (1) to the provision of healthcare to me, (2) to any of my past, present, or future health conditions, or (3) to the past, present, or future payment for any provision of healthcare to me. The information that is protected includes information related to my physical or mental health.
I understand that I have the right to request that the practice restrict its uses and disclosures of my protected health information that the practice is otherwise permitted to make for treatment, payment, and health care operations. NFMD, however, is not required to agree to these restrictions. Nevertheless, if NFMD agrees to any restrictions, those restrictions are binding on it.
Finally, I understand that I have the right to revoke this consent in writing, except to the extent that NFMD has acted in reliance on it.
I give my consent for NFMD, its staff, and business associates to use my medical record for data gathering and research purposes. I understand that ALL identifying information in my record will be coded for confidentiality.
I understand that all patient and medical provider communication is and will be held in the strictest confidence.
FINANCIAL POLICY AND PROCEDURES
I acknowledge that I am responsible, at the time of service, for all expenses incurred during my visit.
NFMD accepts non-cash payments by check and credit card (Visa, Discover, American Express and MasterCard). NFMD will assist me in paying owed amounts through the option of payment plans with third party financing options, monthly automatic withdrawal of an agreed upon amount in writing from a checking account or credit card account over a defined period.
All delinquent payments are handled in accordance with applicable banking laws and regulations.
Credit Card on File
The diagnostic practice of NFMD requires keeping a credit or debit card on file as a convenient method of payment for the portion of services and cost sharing due that my insurance company identifies as my financial responsibility. Following a procedure, I will receive an explanation of benefits (EOB) from my insurance company, including a notifying NFMD of my benefits and what amount is considered the patient responsibility.
After NFMD receives this information, they will mail a statement for any balance due, and I will be given seven (7) calendar days to respond from the date of the statement if I have another payment source I prefer to use.
If NFMD does NOT hear from me, the amount due will be paid from the payment source they have on file. This payment source will be considered valid until expiration of the card. Credit card information is kept confidential and secure and payments to a credit card are processed only after the claim has been filed and processed by the insurer, and the insurance portion of the claim paid.
This authorization relates to all payments not covered by my insurance company for services provided to me by FMD. This authorization will remain in effect until I cancel this authorization with thirty (30) calendar day written notification, and the account must be in good standing.
NFMD will offer a discount (time of service payment discount) should I not have insurance or should I specifically elect to not use my insurance for payment. The amount I will pay is determined from a defined fee schedule, and considered payment in full. I understand that the time of service discount applies to all patients for services provided who elect to not use their insurance as a means of payment.
I understand that NFMD has agreed to furnish the diagnostic services I have requested or recommended by a healthcare provider of NFMD in exchange for payment in full from me at the time of service. The “time of service discount” is offered to me because I do not have insurance available to pay for all or a part of the service to be furnished by NFMD, and I have agreed to pay in full for services at the time of service.
I further acknowledge and attest that I do not have insurance coverage for this service, or that I have made the sole and personal decision to not use my insurance coverage, and will in no way file a claim for this service with any insurance carrier at any point in the future.
Financial Responsibility Resulting from Insurance
I understand that I am responsible for my cost sharing, as defined by my insurance carrier at the time of service.
NFMD will submit claims to my insurance carrier for primary and secondary insurance covered services. NFMD requires a credit card or debit card on file as a convenient method of payment for the portion of the services and costing sharing due that my insurance company identifies as my financial responsibility.
Insurance Policy Provision
I understand for purposes of this document that “insurance carrier” shall mean a health plan or insurance company and benefit plans offered by similar organizations or other types of benefit plan structures.
“Insurance carrier” shall include programs offered by The Centers for Medicare and Medicaid Services, related Medicare replacement plans, secondary insurance plans, related Medicaid replacement plans, programs offered by the Department of Defense, and all organizations offering a form of health care or medical benefit coverage.
NFMD may or may not participate with my insurance carrier. It is my responsibility to determine the financial obligations of care.
My insurance policy is a contract between me and the insurance carrier. It is my responsibility to know the benefits and provisions of my insurance policy, and I am ultimately responsible for all charges incurred at NFMD.
If I have any questions or concerns regarding the benefits of my policy, I will contact my insurance company directly. I am responsible for all charges denied or reduced by my insurance carrier.
A current insurance identification card is required at each visit. If my insurance cannot be verified at the time of my visit, I will be obligated to pay for services until confirmation of my insurance coverage can be obtained.
I shall supply current and accurate information regarding my insurance policy.
Referrals, Pre-Certifications and Authorizations
I understand that my insurance carrier may require that I have a referral to be seen, that pre-certifications to receive services or authorizations may be required, and that I shall be solely responsible to obtain required approvals and referrals to receive care.
I understand that if I do not have or obtain necessary referrals, authorizations or non-routine care may result in me being responsible for payment for those services.
Non-Covered Services, as defined by my insurance carrier, will be required to be paid for at the time of service. Non-Covered services could include services previously covered by my insurance carrier but are services that have a limitation on coverage making a covered service a non-covered service.
The determination of coverage is defined by my insurance carrier and is subject to my certificate of coverage and policy with the insurance carrier that I have selected to assist in the obligation of payment for services. I understand that it is my responsibility to contact my insurance carrier regarding my specific plan structure and coverage.
Returned Check or Declined Credit Card Fees
I understand that if NFMD receives a returned check written by me (or on my behalf) or my credit card on file was declined and unable to process over a seven (7) day period, I will be charged a fee of thirty dollars ($30.00).
Failure to repay the returned check or update your credit card on file may result in collection proceedings and may lead to dismissal of me as a patient from New Frontier Mobile Diagnostics.
I understand that my account balance must be paid within thirty (30) calendar days, but not later than ninety (90) calendar days after I receive a statement reflecting my account balance.
Account interest will be calculated each month on the amount of the unpaid balance (referred to as Previous Balance) after deducting payments or adjustments and before adding new services.
After ninety (90) calendar days from the date of the procedure, I will be charged interest rates permitted by law on a monthly basis thereafter until the balance is paid in full.
Account Interest is only applied to amounts I may owe, and not on those amounts owed on my behalf by my insurance carrier.
Any balances determined as patient responsibility that remain unpaid after ninety (90) calendar days will be subject to an in-house review. If at that time satisfactory payment arrangements have not been established, I understand that I may receive a letter from NFMD notifying me that I have until the end of the current month or date noted in the letter to pay my balance in full, or my account will be forwarded to an outside collection agency and I will be subject to an additional processing fees in addition to any Account Interest, as permitted by law.
I further understand that I may not be allowed to schedule any further appointments with NFMD, receive any medication refills, or seek any medical advice of any kind from NFMD until this collection balance is paid in full, except if I am hospitalized or in a limited post-operative follow-up period.
In the event my account is sent to an outside collection agency, I understand that I will be obligated to pay all collection costs, expenses, and reasonable attorney’s fees and court costs should the collection proceedings advance to litigation.
The following are some but not all service fees assessed by the practice. Service fees are subject to change at the discretion of the practice.
Medical Records Releases
NFMD will only release medical records when a valid, HIPAA-compliant authorization or a court-ordered subpoena is received. Due to increasing costs of office supplies, equipment, and postage, NFMD will assess appropriate fees for the copying and mailing of medical records.
Please contact the NFMD Medical Records Department for further information regarding any specific request for copies of medical records.
I understand that NFMD may, but is not required to, call me to confirm my upcoming appointment date and time. I understand that this is a courtesy and that I am ultimately responsible to keep my office appointment.
I understand that NFMD may charge a $35.00 missed appointment fee and that I will personally pay the fee for appointments missed where I neglected to notify the practice in a timely manner. Missing appointments may lead to termination as a patient from the practice.
NFMD maintains an economic hardship policy for patients unable to meet the financial obligations of services rendered. The policy allows NFMD to write down the balance owed when income levels do not meet a threshold calculated as a percentage of the federal poverty level.
Patients may qualify for such discount once per year when meeting the written definition maintained by the Business Office of an economic hardship discount.
The classification of economic hardship requires documented proof from the patient in accordance with written guidelines that may include disclosure of IRS annual tax filing returns to the Business Office.
In cases where NFMD is not recognized as a participating provider and considered “out-of-network,” NFMD may elect to notify and provide full disclosure upon submission of a claim to my insurance carrier that NFMD will offer a discount to me as their insured member.
NFMD will bill my insurance carrier its full charge and then discount the patient portion of the payment to usual and customary as defined by my insurance carrier. Should my insurance carrier offer payment to NFMD at the discounted rate offered to me as the patient, NFMD will accept the payment from the insurer as payment in full.
NFMD at no time is charging two different prices for the same service, nor is pricing based on the fact that an insurance company may be paying for all or a part of the service rendered.
This is not a waiver or discount of any co-payment, coinsurance or deductible amounts owed for services rendered and is not offered and should not be interpreted as an “inducement” to have services rendered.
Final Costs of Services
I understand that I may inquire about costs of diagnostic services.
I also understand that NFMD representatives can only estimate potential costs and cannot guarantee my final costs until all procedures have been performed and documentation has been reviewed by NFMD business office.
I further understand that after review of my procedures, I may receive a statement for additional expenses. The practice will comply with requests for estimate of charges and will supply that to me within five (5) business days after the date on which the estimate is requested.