I have read the provided policy regarding my financial responsibility to Medical Health Associates, for providing wellness and medical services. I certify that the information I provided is, to the best of my knowledge is current, true and accurate. I authorize my health plan to pay any benefits directly to Medical Health Associates the full and entire amount of bill incurred. As applicable, I agree to pay any amount due after payment has been made by my health plan.
I understand I am responsible for paying my copay upon arrival at each visit.
High Deductible Plan
I understand that with a high deductible health plan, Medical Health Associates will expect a payment at time of service of no less than a minimum of $70.00 or perhaps more depending on the services being rendered. Medical Health Associates will submit the claim and bill me for any remaining balance.
Self-Pay, Non-Participating, No Fault Insurance and Workers’ Compensation
I understand that as self-pay, no fault or having a health plan with which Medical Health Associates does not participate that I will be responsible for all medical services rendered at Medical Health Associates. I agree to pay Medical Health Associates for the full amount of charges related to the office visit and any treatment/procedure rendered at each visit. Medical Health Associates will provide an itemized receipt for the services reflecting the payment made.
Missed Appointment Policy
I understand that fee for missing an appointment fee is $50.00 per occurrence.