For Clients & Families: Forms

Financial Agreement

**Please note, if the client is 14 -17 years old they need to sign these documents with their parent/legal guardian.  Clients 18 or older should sign independently, without their parent/legal guardian)**

Financial Agreement

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We appreciate the confidence you have shown in choosing us to provide for your health care needs. The service you have elected to participate in implies a financial responsibility on your part. The responsibility obligates you to ensure payment of any charges not covered by your insurer, payment of any deductibles, co-pays and co-insurances as determined by your contract with your insurance carrier.
I authorize Catalpa Health to release to the entities below, information from the client’s records relating to the identity, diagnosis, and treatment for the purposes specified:
  1. Payment for services rendered. I recognize and accept responsibility for any balance, including those not covered by the client’s insurance plan or third-party payer. Failure to provide current insurance results in a self-pay account. Payments in arrear may be submitted to a collection agency
  2. Parent/Guardian who is responsible for charges incurred by a minor child for the sole purpose of obtaining information & signatures mandated for insurance billing.
  3. To my physician or the Catalpa Health’s Medical Director for the purpose of obtaining prescriptions for treatment as required by law in order to received mandated health insurance benefits.
  4. I hereby authorize payment of insurance benefits directly to Catalpa Health, 4635 W College Ave, Appleton, WI 54914
  5. I acknowledge that a detailed Financial Policy is available upon request.
Non-discrimination Clause: Catalpa Health operates under the provisions of Title VI of the Civil Rights Act of 1964. Under this act, any provider of services receiving federal funds must comply with the intent of the act. This means there shall be no discrimination because of sex, race, color, or national origin. This Title also provides for strict complaint procedures. WPS 193-6-69.
Your Rights and Protections Against Surprise Medical Bills: When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)? When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. “Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit. “Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care — like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
  1. Emergency services: If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
  2. Certain services at an in-network hospital or ambulatory surgical center: When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out of network. In these cases, the most those providers may bill you is your plan’s in-network cost sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
  1. You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network).
Your health plan will pay out-of-network providers and facilities directly. Your health plan generally must:
  1. Cover emergency services without requiring you to get approval for services in advance (prior authorization).
  2. Cover emergency services by out-of-network providers.
  3. Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  4. Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact the Center for Medicare and Medicaid Services at 1-800-985-3059. Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.
Address*
Signature of Parent/Legal Guardian (Guarantor)
Signature of Client (if age 14 or older)
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