Agreement for Payment of Services
Last updated: November 15th, 2021
KMG Medical Group MO, P.C. and its affiliated entities KMG Medical Group TX P.A., KMG Medical Group NJ, P.C. and Michael Karagas, M.D., P.C., (collectively defined as “KMG”) is committed to providing the best quality healthcare services.
Patients Using Insurance
If you choose to use insurance for the payment of KMG services, and KMG is in-network for such insurance, by accepting this Agreement, you agree to allow KMG to disclose your information to the insurance plan you provided to KMG and any other health plan that pays for the cost of my medical or health care services now or in the future, for the purposes of KMG obtaining reimbursement for the services provided to me or otherwise communicating with the health plan regarding payment for services (this “Authorization”). This disclosure may include all health information pertaining to my medical history, mental or physical condition, and treatment and services received, including demographic information.
Additionally, you agree to hereby assign KMG all right, title, and interest in any and all health insurance or other health care benefits payable to you or on my behalf by any in-network insurance payer for medical treatment rendered by KMG. You also authorize direct payment to KMG of all insurance benefits payable to you for such medical treatment. In the event an insurance payer pays you directly, you agree to immediately pay such amounts to KMG.
You understand that your insurance payer may pay less than the actual bill for services. You acknowledge that you are still responsible for paying KMG for any and all amounts not paid by the insurance payer, including non-covered charges and all copayments, coinsurance, and deductibles. You understand that if insurance requires a referral, you are responsible for obtaining one prior to an appointment. In the event any collection action is necessary to collect amounts you owe to KMG, you agree to pay all expenses associated with such action, including but not limited to collection agency fees and attorneys’ fees. This assignment will remain in place until revoked by you.
You understand that information used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient of such information and may no longer be protected by federal or state law. However, state law may prohibit the person receiving my health information from making future disclosures of my information unless another authorization for disclosure is obtained from me, or unless such disclosure is specifically required or permitted by law. KMG will not condition my treatment, payment, enrollment or eligibility for benefits on whether you provide authorization for the requested use or disclosure.
You understand that you have the right to: inspect or copy the protected medical information to be used or disclosed as permitted under federal or state law; refuse to agree to this Authorization; and receive a copy of this Authorization. You have read the above information and authorize the disclosure of my information by KMG or the purpose described herein.
If you choose to self-pay, by accepting this Agreement, you acknowledge that: 1) you do not have any health insurance through a PPO, HMO, Medicaid or Medicare or any other insurance plan; or 2) you have health insurance but you do not want to use any insurance benefit for these services, acknowledging that KMG does not accept any health insurance. Your insurance policy is a contract between you and your insurance company. It is your responsibility to know your benefits, and how they will apply to your benefit payments, and we take no responsibility to understand or be bound by the terms and conditions of such insurance.
By agreeing to this Agreement, you are electing to purchase services that may or may not be covered by your insurance if you obtained those services from a different provider. You have selected services for purchase from us on a self-pay basis. In other words, you have directed us to treat your purchase of these services as if you are an uninsured patient and you agree to be 100% responsible for full payment of the listed price of the services. There is no guarantee your insurance company will make any payment on the cost of the services you have purchased.
KMG has provided you with the charges, in advance, for the services you have requested. By signing, you agree to pay these charges in full as a self-pay patient, electing not to use an insurance policy benefit. You have been given a choice of different services, along with their costs. You have selected the services and are willing to accept full financial responsibility for payment.
I certify that I have read and understand the foregoing and received a copy thereof. I am the patient, the patient’s legal representative, or am otherwise duly authorized by the patient to sign the above and accept its terms on his/her behalf.