FINANCIAL POLICY AND FEE AGREEMENT 11 17 14 English and Spanish.

CLIENT FINANCIAL POLICY AND FEE AGREEMENT

Thank you for choosing us as your health care provider. We are committed to your treatment being successful and hope that your experience here is positive. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our Financial Policy.

  • All clients must complete our release of information form at the time of intake.
  • Payment for services, including full fee if uninsured, copayments, co-insurance, payment plans are due at the time of sign in for your visit.
  • If you incur a past-due balance at any time, payment in full is expected at your next visit.
  • If you miss two co-payments or two payment plans you will not be rescheduled for services until your payment has been received.
  • If you leave the agency with a past due balance, payment is expected before you may return for services.
  • You are responsible for updating CHR regarding any changes in your insurance immediately. Failure to do so may result in a balance due by you.
  • We accept cash, check and charge / credit cards at all locations.

Commercially Insured Clients: CHR will bill your insurance as a courtesy. You are responsible for knowing your insurance mental health benefits. CHR will verify your eligibility and collect payment per the eligibility verification. However, once your insurance processes your claim you will be billed for any additional patient responsibility due according to your insurance. Patient responsibility is due at the time of service.

Self Pay / Uninsured Clients: Payment in full is expected at the time of service. We have staff to help you determine if you are eligible for state insurance. You may also be eligible for an ACA (Access Health Care plan). Please log onto www.accesshealthct.com to see if you are eligible and/or to apply. CHR has a Sliding Fee Scale based on income level. Please contact the front desk if you should need assistance when applying for Sliding Fee Scale or Access Health CT.

Medicaid Clients: CHR participates with Medicaid. However, if you are on a spend-down you will be responsible for payment until your spend-down is met.

Medicare Clients: CHR participates with Medicare. After your yearly deductible is met, you will typically be responsible for 20% of charges that are considered your co-insurance. If you have Medicaid as a secondary insurance, Medicaid will be billed for you.

CHR reviews published charges every year. If you have any questions regarding our published charges, please feel free to contact the front desk.

I understand that I will be responsible for all patient responsibility according to how my insurance company processes my claim and /or full payment if I am uninsured. I will be sure to notify CHR of any changes in my insurance immediately.

ACUERDO DE TARIFAS Y POLÍTICA DE FINANCIACIÓN DEL CLIENTE

Le agradecemos que nos haya elegido como sus proveedores de atención médica. Estamos comprometidos a que su tratamiento sea un éxito y esperamos que su experiencia con nosotros sea positiva. Por favor entienda que el pago de su factura se considera parte de su tratamiento. Lo siguiente es una declaración de nuestra Política de Financiación.

  • Todos los clientes deben completar nuestro formulario de autorización de información en el momento de la admisión.
  • El pago por los servicios, incluido el cargo completo si no tiene seguro, y los copagos, coseguro, planes de pago, etc. son pagaderos en el momento de registrarse para su visita.
  • Si en algún momento incurre en un saldo vencido, se espera el pago completo en su próxima visita.
  • Si no cumple con dos copagos o dos planes de pago, no se le dará cita para el servicio hasta que hayamos recibido su pago.
  • Si se va de la agencia con un saldo vencido, se espera que lo pague antes de poder volver a recibir servicios.
  • Usted es responsable de actualizar inmediatamente a CHR en relación con cualquier cambio en su seguro. Al no hacerlo puede dar lugar a un saldo a pagar por usted.
  • Aceptamos efectivo, cheques y tarjetas de crédito/cargo en todos los centros.

Clientes comercialmente asegurados: CHR facturará a su seguro como una cortesía. Usted es responsable de conocer sus beneficios del seguro de salud mental. CHR verificará su elegibilidad y cobrará el pago por la verificación de la elegibilidad. Sin embargo, una vez que su seguro tramite su reclamación, se le cobrará por cualquier responsabilidad de pago adicional del paciente que se deba de conformidad con su seguro. La responsabilidad del paciente es pagadera en el momento del servicio.

Pagos por cuenta propia/ Clientes sin seguro: Se espera el pago total en el momento del servicio. Tenemos financiero que puedan ayudarle a determinar si puede ser elegible para el seguro estatal. CHR tiene una escala de pago desplazamiento basado en el nivel de ingresos. Por favor ingrese a la página www.accesshealthct.com para ver si es elegible y/ o para llenar la solicitud. Por favor de conectarte con recepción para asistencia en cómo aplicar o ayudarle atreves de Access Health.

Clientes de Medicaid: CHR participa con Medicaid. Sin embargo, si usted tiene un deducible, será responsable por el pago hasta que haya pagado el deducible.

Clientes de Medicare: CHR participa con Medicare. Después de cumplir con el deducible anual normalmente será responsable del 20% de los cargos que se consideran su coseguro. Si tiene Medicaid como un seguro secundario, se facturará a Medicaid en vez de a usted.

CHR analiza los cargos financiero anualmente . Si usted tiene alguna pregunta acerca de nuestras tarifas, no dude en contactar con recepción.

Entiendo que seré responsable por toda la responsabilidad de pago del paciente según como mi compañía de seguros tramite mi reclamación y/o el pago completo si no tengo seguro. Me aseguraré de notificar inmediatamente a CHR de cualquier cambio en mi seguro.

Client Protections Against Surprise Medical Bills

Sections 1557  and 504 require covered entities to take appropriate steps to ensure effective communication with individuals with disabilities, including provision of appropriate auxiliary aids and services. Auxiliary aids and services may include interpreters, large print materials, accessible information and communication technology, open and closed captioning, and other aids or services for persons who are blind or have low vision, or who are deaf or hard of hearing. Information provided through information and communication technology also must be accessible to individuals with disabilities, unless certain exceptions apply. Providers and facilities are reminded that the disclosure notice must comply with applicable state or federal language-access standards.

Use of plain language

Healthcare providers and facilities are encouraged to use plain language in the disclosure notice and test the notice for clarity and usability when possible.

Plain language, accessibility, and language access resources:

NOTE: The information provided in these instructions is intended to be only a general summary of technical legal standards. It isn’t intended to take the place of the statutes, regulations, or formal policy guidance on which it is based. Refer to the applicable statutes, regulations, and other interpretive materials for complete and current information.

 

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