Franck's Infusion Pharmacy Financial Policy/Patient Agreement and Consent
Franck's Infusion Pharmacy Financial Policy
Patient Agreement and Consent
202 SW 17th Street, Ocala, FL 34471
352-622-4148 Fax 352-622-3318
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Patient Name: Date:
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Address: City: Zip Code: Telephone:
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Thank you for choosing us as your home health services provider. We are committed to your home care being successful. Please understand that payment of your bill is considered part of your care. The following is a statement of our Financial Policy, which we require you to read and sign prior to any pharmaceuticals, medical equipment, supplies or services being rendered to you. By signing this policy/agreement, the undersigned, being the above named Patient, his/her guardian or representative payee, desires to purchase, as or on behalf of Patient pharmaceuticals, medical equipment, supplies and/or services from Franck's Infusion Pharmacy and its affiliates.
Acknowledgment of Medical Responsibility and Informed Consent
The undersigned, as or on behalf of Patient, understands that (1) Patient is under the supervision and control of his/her attending physician; (2) Patient's physician has prescribed the pharmaceuticals, medical equipment, supplies and/or services noted as part of Patient's treatment; (3) Franck's Infusion Pharmacy services do not include diagnostic, prescriptive or other functions typically performed by licensed physicians; and (4) Patient's physician is solely responsible for diagnosing and prescribing pharmaceuticals, medical equipment, supplies, services or other therapies for Patient's condition and for otherwise controlling Patient's medical care. The undersigned, as or on behalf of Patient, has been informed by Patient's physician of the possible increased risks associated with in home care, including possible delays in receiving treatment for life threatening conditions as a result of being outside the hospital setting. The undersigned, as or on behalf of the Patient, has discussed his/her concerns with Patient's physician and has had all associated questions answered to his/her satisfaction.
Regarding Insurance
We may accept assignment of your insurance benefits. However, the balance on your bill is your responsibility whether your insurance company pays or not. The undersigned agrees to pay for all pharmaceuticals, equipment/supplies/services provided by Franck's Infusion Pharmacy to Patient. We cannot bill your insurance company unless you have given us all of your insurance information and any claim forms needed to file. Your insurance policy is a contract between you and your insurance company. We are not party to that contract. In the event we do accept assignment of benefits and your insurance company does not pay within 45 days, the balance will be billed to you. If payment is not made, Franck's Infusion Pharmacy will pursue its normal collection policy. Please be aware that some and perhaps all of the services provided may be non-covered services and not considered reasonable and necessary under your insurance program.
Regarding Insurance plans where we are a participating provider: All co-pay and deductibles are due prior to service. In the event that your insurance coverage changes to a plan where we are not a participating provider, refer to the above paragraph.
If Medicare is your primary insurance and we agree to accept Medicare's assignment of benefits, you will still be responsible for Medicare's calendar year deductible and all co-payments based on Medicare's allowed amounts.
Adult patients: Adult patients are responsible for payment in full at the time of service unless other arrangements have been made prior to service.
Minor patients: The parents or guardians of the minor are responsible for full payment.
Authorization for Release of Medical and Other Information
The undersigned, as or on behalf of Patient, understands that Franck's Infusion Pharmacy follows HIPPA guidelines regarding protected health information. Franck's Infusion Pharmacy is authorized by the undersigned to use the Patient's health information to determine applicable benefits, process claims for pharmaceuticals/equipment/supplies/services provided by Franck's Infusion Pharmacy and/or to conduct quality assurance or utilization reviews. The undersigned hereby authorizes all medical personnel, insurers and other third party payor(s) to disclose to Franck's Infusion Pharmacy any information necessary to assist in the processing of claims, verifying payments or providing care to the Patient.
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Beneficiary/Patient or Third Party Signer Date
If beneficiary is unable to sign, complete the following section (May be completed by employee)
__________________________________________________ ____________________ ________________________________
Beneficiary Name Name of Signer Date Relationship to Beneficiary/Patient
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After Hours and Holiday Referral Policy
The undersigned understands that the pharmaceuticals/equipment/supplies/services that my physician has ordered for the Patient must be verified as a covered service under the Patient's major medical/health insurance policy. An amount of medication and necessary supplies will be provided to cover the Patient's therapy needs until such time that insurance eligibility and coverage can be established. Determination of benefits will be performed at the start of the next business day following the Patient's referral. The Patient agrees to assume financial liability for any services rendered that may be non-covered by major medical/health insurance coverage. The undersigned also understands that if coverage is not available for the prescribed therapy, the undersigned will assume complete financial responsibility for the continuation of therapy or will be discharged from services. Franck's Infusion Pharmacy reimbursement specialist will contact the undersigned as soon as possible to inform the undersigned of the coverage verification and/or possible payment arrangements.
Miscellaneous
The undersigned certifies that the information provided to Franck's Infusion Pharmacy by or on behalf of Patient under Medicare (Title XVIII of the Social Security Act) and/or any other public or private health is correct. Patient, if physically and mentally competent, must sign this Patient Agreement and Consent on his/her own behalf. If Patient cannot sign for himself/herself, the source of the undersigned's authority to sign on behalf of the Patient must be stated. This Patient Agreement and Consent is used in lieu of the Patient's or his/her representative's signature on the 'Request for Payment' HCFA-1500 and on other health insurance claim forms requiring signature and thus, is an extension of those forms. Any person who misrepresents or falsifies information in making a Medicare claim may, upon conviction, be subjected to fines and imprisonment under Federal Law. Penalties may also result from falsification or misrepresentation of other health insurance claims. A copy of this Patient Agreement and Consent may be used in place of the
original.
Primary Insurance Coverage Information
Name of Insurance Company :________________________________ Effective Date: __________________
Percent of Coverage: _________________ Deductible:____________ Met? Yes □ No □ Unknown □
Out of Pocket: _______________________ Met? Yes □ No □ Lifetime Maximum: __________________
Secondary Insurance Information
Name of Insurance Company :________________________________ Effective Date: __________________
Percent of Coverage: _________________ Deductible:____________ Met? Yes □ No □ Unknown □
Out of Pocket: _______________________ Met? Yes □ No □ Lifetime Maximum: __________________
Equipment: ______________________________________________ Replacement Cost: __________________
Estimated Patient Responsibility: _____________________________ (if not paid by insurance).
The undersigned certifies that (1) he/she is the Patient or is duly authorized to execute this Patient Agreement and Consent and accept its terms on behalf of Patient and (2) he/she has read the foregoing and received a copy of this Patient Agreement and Consent, including a copy of the Patient Rights and Responsibilities on the reverse side hereof.
___________________________________________________ ________________________________________________________
Beneficiary/Patient or Third Party Signer Date
If beneficiary is unable to sign, complete the following section (May be completed by employee)
__________________________________________________ ____________________ ________________________________
Beneficiary Name Name of Signer Date Relationship to Beneficiary/Patient
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