Welcome to Eberi Clinic’s Financial Responsibility Agreement. This agreement outlines your financial responsibilities related to the healthcare services provided by our clinic. Please read this agreement carefully and contact us if you have any questions or concerns.
Patient Financial Responsibilities
- Insurance Coverage Verification: It is your responsibility to provide accurate and up-to-date information about your insurance coverage, including insurance cards, policy numbers, and any changes in coverage. We will verify your insurance coverage and benefits, but ultimately, you are responsible for any expenses not covered by your insurance plan.
- Co-payments, Deductibles, and Coinsurance: If your insurance plan requires co-payments, deductibles, or coinsurance, you are responsible for paying these amounts at the time of service. We accept various forms of payment, including cash, credit/debit cards, and electronic funds transfers.
- Uninsured or Self-Pay Patients: If you do not have insurance coverage or if your insurance plan does not cover certain services, you are responsible for the full cost of the services rendered. We offer flexible payment options and financial assistance programs for eligible patients.
- Billing Inquiries and Disputes: If you have questions or concerns about your medical bills or insurance claims, please contact our billing department promptly. We will work with you to resolve any billing issues or disputes in a timely and fair manner.
- Financial Assistance: If you are experiencing financial hardship and are unable to pay your medical bills, you may be eligible for financial assistance or payment arrangements. Please contact our billing department to discuss your options.
Clinic Financial Responsibilities
- Transparent Billing Practices: We are committed to providing clear and transparent billing practices, including providing detailed explanations of charges. If you have any questions about your bill, please don’t hesitate to ask.
- Insurance Claims Processing: We will submit insurance claims on your behalf and work with your insurance company to maximize your benefits. However, we cannot guarantee payment from your insurance company and may require your assistance in resolving any claim denials or discrepancies.
- Patient Advocacy: We will advocate on your behalf to ensure that you receive fair and reasonable reimbursement from your insurance company for covered services. We understand the complexities of insurance billing and will work diligently to address any issues that arise.
Agreement Acknowledgement
By signing this Financial Responsibility Agreement, you acknowledge that you have read and understand your financial responsibilities as outlined above. You agree to comply with the terms of this agreement and to provide accurate information related to your insurance coverage and financial status.
Thank you for choosing Eberi Clinic for your healthcare needs. If you have any questions or need assistance, please don’t hesitate to contact us.
