I/Client understand that clients are to meet certain insurance billing requirements.
In order to bill the specific insurance provider, attendance to facilitated groups and private sessions are required. Should I/client not meet the minimum attendance requirements communicated by the insurance providers, Riverside Recovery reserves the right to bill under “self-pay” for the specific services that were recorded as an unexcused absence.
Absences can be deemed “excused” by our Nursing/Medical team and/or Therapist only.
I/Client understand that I am expected to pay the Co-Insurance stated above as designated by my insurance provider.
I/Client understand that if I/Client am quoted a “package” price for a specified number of days and I/Client decides to discharge against medical and/or clinical advice, the fee for Client’s stay at Facility will be converted to the standard daily bill rates listed above for the level of care that Client was assigned.
Facility does not provide refunds of any monies paid by or on behalf of Client if Client leaves Facility against medical and/or clinical advice or for major rule violations. All services are non-refundable, unless approved by CEO. The payer will be refunded any unused portion, less $1,000.00 administrative fee if applicable.
I/Client understand that as a part of my commitment to my recovery process, I/Client agree to be personally financially responsible for all fees identified above by the Facility, in reference to my treatment. This includes but is not limited to intake fees, assessment fees, orientation fees, drug test fees, group fees and any other fees for procedures deemed necessary for my treatment
I/Client understand that all fees deductibles, co-payments, or full-fee for services are due at the time of the assessment unless special arrangements are made with Riverside Recovery of Tampa, LLC (Facility). I/Client understand that this office will not bill insurance companies and other third-party payers and cannot guarantee such benefits, and is not responsible for collection of such payments unless prior arrangements have been made between Facility, and the insurance provider.
Should the above-named Client default on or become delinquent in payment of fees connected with treatment by Facility, it may become necessary to pursue collection or legal action. It is therefore understood that the above-named Client will be responsible for any and all fees connected with such action including collection fees, attorney fees, legal and court costs and any additional costs related to this action. I/Client understand that violations of the Facility program rules or non-compliance may be grounds for termination of my treatment. No refunds for advance fee payment shall be made in such cases.
Facility will bill insurance carriers on behalf of Client where applicable. This is a service we provide for our clients. Client is still responsible for all charges incurred. Refer to Assignment of Benefits.
Facility has contractual agreements with many insurance carriers. Some contracts require that we accept payment from the insurance carrier as payment in full, in such cases, clients may not be responsible for co-payments and deductibles.
If Client’s insurance carrier fails to remit payment for services within ninety (90) days, Client will be billed for the balance on the account. All statements are due in full upon receipt.
Facility does not provide refunds of any monies paid by or on the behalf of the Client if the Client leaves the Facility against medical and/or clinical advice or for major rule violations.
If Client is transferred for therapeutic or medical reasons, any monies paid by or on behalf of Client may be refunded as appropriate, less Facility’s full per diem rate for each day Client was present at Facility.
Initial payment for treatment is due upon Client’s admission unless insurance assignments are accepted. Subsequent payments are due on the first day of each subsequent treatment period.
Should the Client incur multiple stays at Facility, any payments made will first be applied to any old balance. The remaining monies will be applied to the current stay at the Facility.
I/Client understand that my (Client’s) records are protected under Federal Confidentiality regulations (42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for Federal laws and 42 CFR Part 2 for Federal regulations) published August 10, 1987, and cannot be disclosed without my (Client’s) written consent unless other provided in the regulations. I/Client understand that my (Client’s) medical record may contain information concerning my psychiatric, psychological, drug or alcohol abuse, HIV/Acquired Immune Deficiency Syndrome (AIDS), and/or related conditions.
I/Client understand that if Client is admitted as self-pay and later decides to utilize any insurance benefits, it will be Client’s responsibility to file the claim with their insurance company. Please note: Insurance is more likely to pay, and sometimes will ONLY pay, if the insurance is pre-certified prior to the admission.
Facility partners with independent outside vendors that provide services for medications, lab tests, physical therapy and any other diagnostic testing. I/Client understand that the fees for these services are billed separately by these vendors and is NOT included in the fees charged by Facility. All questions regarding billing from these vendors must be done directly with the specific vendor and not Facility.
Per Federal and State regulations, there may be a fee associated with obtaining copies of your medical records. Facility charges $0.20 per page for the sending of medical records to another facility.
Facility charges $25.00 per document for the completion of the following items: Short Term Disability (STD), Long Term Disability (LTD), and Family and Medical Leave Act (FMLA).
I/Client have read the Patient Rights form and reviewed the fee schedule. In addition, I/Client have been given the opportunity to ask questions about this form and any questions that I/Client had were answered to Client’s satisfaction. In signing this form, I/Client understand my rights as a client at Facility and understand my financial responsibility. I/Client understand that if my insurance company denies coverage and/or payment for services provided to Client by Facility, I/Client assume financial responsibility and will pay all such charges in full.