This Financial Responsibility Agreement (the “Agreement”) is made and entered into between Quality Infusion and Wellness Clinic, and its affiliates under common control or ownership (“Quality Infusion and Wellness Clinic or Q-Infusion Therapy”), and the client receiving mental health services or their personal representative (“You”).
BY CHECKING THE BOX “I AGREE” YOU INDICATE YOU HAVE READ, ACKNOWLEDGE, AND AGREE TO THIS FINANCIAL RESPONSIBILITY AGREEMENT. IF YOU DO NOT AGREE TO THESE TERMS, YOU CAN NOT ACCESS OUR SERVICES AND MUST EXIT NOW.
- Your Responsibility for Payment. You are responsible for payment for all services provided by Quality Infusion and Wellness Clinic. You understand that some services may not be covered by insurance. It is your responsibility to ensure your health plan benefits can be used for our services. To verify, please call the number on the back of your insurance card.
- Services Covered by Insurance. Quality Infusion and Wellness Clinic will use the insurance information on your file to bill for services, as applicable. You understand that insurance payments from the insurer for services rendered by Quality Infusion and Wellness Clinic may be addressed and sent directly to you. In such an event, you agree to endorse and mail any payments and corresponding explanations of benefits to Quality Infusion and Wellness Clinic, Address Coming Soon. Richmond, TX 00000
- Cancellations and No-Show Fees. If you cancel within the twenty-four (24) hours before the appointment, or if you fail to cancel the appointment and do not attend the appointment, you may be subject to a cancellation fee, up to the full cost of the session at the then-current self-pay rate.
- After your insurance provider(s) have processed the associated claim, Quality Infusion and Wellness Clinic notifies you of any outstanding balances such as copays and coinsurance, appointment cancellation, and no-show fees. The credit card on file is charged seventy-two (72) hours from the notice.
- Your Information. You agree to provide and update Quality Infusion and Wellness Clinic with accurate personal information including but not limited to contact information and insurance information. Your failure to update this information may result in inaccurate charges or delayed refunds.
- Collection Fees. In the event you have not made alternative arrangements for payment and this account is placed with an attorney or collection agency, you are responsible for collection fees, attorney’s fees, and court costs.
- Credit Card Authorization. You understand that Quality Infusion and Wellness Clinic will charge your credit card on file for financial responsibilities in connection with your care and treatment, including but not limited to any remaining balance, service fees, and appointment cancellation fees. THE CARDHOLDER NAMED ON THE CREDIT CARD ON FILE WITH SONDERMIND IS ULTIMATELY RESPONSIBLE FOR THE PAYMENT OF ANY OUTSTANDING BALANCE ON YOUR ACCOUNT.
- You hereby certify that you do not have Medicaid as the primary source of insurance. You understand that enrollment in Medicaid coverage as the primary source of insurance disqualifies you from using Quality Infusion and Wellness Clinic services, even if you are willing to self-pay for services received.
Right to a Good Faith Estimate. If you are not enrolled in a health benefits plan or choose to not use your health benefits to pay for therapy services with Quality Infusion and Wellness Clinic, you have the right to receive a Good Faith Estimate for the total expected cost of services. Please submit your request for a Good Faith Estimate to firstname.lastname@example.org. If you receive a bill from us that is at least $400 more than the Good Faith Estimate, you can dispute the bill by emailing email@example.com. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 844-256-9897.