FINANCIAL AGREEMENT POLICY
Key Connections ABA Services, LLC believes that part of good health care practice is to establish and communicate an office and financial policy to our patients. We are dedicated to providing the best possible care for you, and we want you to have a full understanding of our policies.
The Financial Agreement is intended to provide patients/legal guardians with an understanding of the financial aspect of healthcare services provided at Key Connections ABA Services, LLC. Patients/legal guardians should read this agreement carefully before deciding and proceeding with care.
1) INSURANCE: We are participating providers with most insurance plans. We will file all the claims for these plans. Please remember that insurance is a contract between the patient and the insurance company and ultimately the patient is responsible for payment in full. As a courtesy to our patients, we will verify your insurance coverage, however, our verification is not a guarantee of benefits payable by your insurance. To bill your insurance and to meet filing guidelines we do ask for a copy of your insurance card and a photo ID
a)If our providers are not listed in your plan’s network, you may be responsible for partial or full payment.
2) POLICY ON NON-COVERED SERVICES: This office offers access to many innovative services and procedures, some of them are deemed as “not covered” by insurance. You will be responsible for payment in full at the time of service.
3) RESPONSIBILITY FOR PAYMENT: I understand that I, personally, am financially responsible to Key Connections ABA Services, LLC for charges not covered by the assignment of insurance benefits and all non-covered charges.
4) AUTHORIZATION & ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize Key Connections ABA Services, LLC to furnish information to insurance carriers concerning my treatments and I hereby assign to Key Connections ABA Services, LLC all payments otherwise payable to me for Key Connections ABA Services, LLC services.
5) SELF PAY PATIENTS WHO ARE INSURED: Self-pay patients will be identified when they make the initial contact with the office and will be defined as a patient who has no health insurance coverage of any kind, including federal and state health care programs such as Medicare and Medicaid or other insurance coverage such as insurance provided by a school, or AFLAC
a) does not claim third party liability for the patient’s health care treatment
b) has no other responsible party covering the expenses associated with the care received from our office Self-pay patients will be required to pay $800.00 for the Initial Assessment (up to 8 hours) prior to scheduling. Any additional charges incurred will be invoiced the first (1) week of each month. All charges are due on or before the fifteenth (15) of each month.
6) BILLING AND COLLECTION FEES: Key Connections ABA Services, LLC will submit a claim for payment to your insurance company. In the event your insurance carrier/company denies the services provided, you will be responsible for the payment in full. We appreciate prompt payment in full for any outstanding balance. If your account is turned over to our collection agency, you agree to pay an additional $50.00 fee to cover the fees imposed to Key Connections ABA Services, LLC by the collection agency to collect the outstanding balance.
7) PAYMENT: is expected at the time of invoice. Payment will include any unmet deductible, co-insurance, co-payment amount, charges not covered by your insurance company. If you do not carry insurance, payment in full is expected at the time of your visit. Self-pay patients will be required to pay $800.00 for the Initial Assessment (up to 8 hours) prior to scheduling. Upon completion of the Initial Assessment the number of hours per day/week will be discussed and outlined in a separate agreement.
8) INVOICING: Notification will be sent to the email address on file from Bill.com with a link to create a username and password to be used whenever needed. Notification will be sent the first (1) week of each month for the prior month. All charges are due on or before the fifteenth (15) of each month through Bill.com.
I have read and understand the practice’s financial policies and I agree to be bound by its terms.
I also understand and agree that such terms may be amended by the practice at any time.