FEE AGREEMENT AS OF 08-21-2023

We know that unexpected medical costs are one of the most common sources of stress on individuals and families. Diligence Care Plus attempts always to keep that stress to a minimum by keeping our fees as low as possible. Please read the attached fee schedule carefully. If you have any questions about the fee schedule, please ask your provider or one of the office personnel. If you are paying part or all your fees with insurance, be aware that most insurance carriers place limitations on the type of service for which they will pay. Your provider may recommend a service, or you may request a service which is not covered by insurance, in which case you will pay the entire fee. When a given service is recommended to you or if you request a service or procedure, make certain that it is clear to you whether your insurance will pay. If you are in doubt, ask our office personnel to check for you or call your insurance provider.

All fees are to be paid at the time of service for in-person visits. For Telehealth visits, all fees, coinsurances, and co-pays are paid at the time of booking. A fee of one- and one-half percent per month (18% per year) may be added monthly to all outstanding accounts more than thirty days.
Certain health insurance plans have pre-arranged contracted fee arrangements that are different than the amounts quoted. Upon verification of your eligibility and benefits, your insurance carrier will be billed for you and your provider will be paid directly by the carrier. The patient will be responsible for any applicable deductibles, coinsurance, and co-payments as described above. If you are not eligible at the time services are rendered or if your insurance carrier does not authorize the services, you are responsible for payment of the quoted fees or the rate negotiated with your insurance carrier, whichever applies.

CANCELED / MISSED APPOINTMENTS
A scheduled appointment means that time is reserved only for you. If an appointment is missed or canceled with less than 24 hours’ notice, the patient is responsible for paying ($100 fee if seen for psychiatric appointments), or ($60 fee for medical appointments).

For patients who request appointments through any third-party service, such as Zocdoc, which charges Diligence Care Plus a specified fee for each patient booking, all fees collected are NON-REFUNDABLE, and the 24-hours cancellation window does not apply. This charge cannot be billed to your insurance plan .......(initial).

MEDICAL RECORDS REQUESTS
I understand I must sign a Release of Information to obtain any medical records. There is a $35 processing fee, due at the time of request. This process will take up to 15 business days .......(initial).

PAPERWORK FEES
We charge a fee of eighty-five dollars ($85) for any paperwork that we complete on your behalf and/or at your request. This includes requests to complete documents online or hard copy of documents. In general, these are documents that are not generated by Diligence Care Plus. Examples of paperwork that we charge a fee for include disability paperwork, work-required forms, school physical forms, and other documents requested by you or another entity on your behalf .......(initial).

There is no charge for issuing you an off-work order. This is usually a document generated by Diligence Care Plus.

DELINQUENT ACCOUNTS
If accounts become delinquent (past 30 days) our office will begin collection procedures. We will attempt to contact you directly. If your account remains delinquent (past 90 days) an outside collection agency may be used and/or small claims court action taken. In such cases, non-clinical information (as given on any intake/consent forms) may be released to assist in the collection of the amount due. Patient responsible for all court and legal fees incurred if the above action is necessary.
If any of the above provisions are not satisfactory, please make alternative arrangements prior to or during your first provider appointment.

Please sign to indicate that you have carefully read and agree to the above conditions even if you missed one or more initials.