Financial Agreement

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INSURANCE INFORMATION

We will be unable to schedule your child for an initial appointment unless all insurance information is provided. Our insurance team will verify network status, but we advise families to contact their insurance carrier to confirm network status, mental health benefits, and telehealth benefits.

Insurance Type (select all that apply):*

No Insurance, will be self pay.

Medicaid (Forward Health)

Commercial Insurance

Medicaid Member ID:

Commercial Insurance - Upload the FRONT of your insurance card.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB.

Commercial Insurance - Upload the BACK of your insurance card.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB.

Commercial Insurance Company Name (required):

Member ID (required):

Group Number:

Effective Date (required):

Subscriber's Name (required):

First Last

Subscriber's Date of Birth (required):

Subscriber's Relationship to Client (required):

Subscriber's Address (required):

Address City State ZIP Code

Subscriber's Employer (required):

Subscriber's Employment Status (required):

Additional Commercial Insurance (required):

Commercial Insurance - Upload the FRONT of your insurance card.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB.

Commercial Insurance - Upload the BACK of your insurance card.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB.

Commercial Insurance Company Name (required):

Member ID (required):

Group Number:

Effective Date (required):

Subscriber's Name (required):

First Last

Subscriber's Date of Birth (required):

Subscriber's Relationship to Client (required):

Secondary Subscriber's Address (required):

Subscriber's Address (required):

Address City State ZIP Code

Subscriber's Employer (required):

Subscriber's Employment Status (required):

Please contact our Insurance Verification Team at (920) 750-7075 to if you have an Employee Assistance Program (EAP) authorization that should be applied. Please note that once the EAP authorization has expired, Catalpa will bill the insurances on file. It is your responsibility to notify Catalpa Health of insurance coverages and/or additional authorizations. If we do not have insurance information, or if there is no active insurance, all future visits will be billed as Self-Pay.

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:

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
Parent/Guardian who is responsible for charges incurred by a minor child for the sole purpose of obtaining information & signatures mandated for insurance billing.
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.
I hereby authorize payment of insurance benefits directly to Catalpa Health, 4635 W College Ave, Appleton, WI 54914
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 are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

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, like a copayment, coinsurance, or deductible. You may have additional 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” means providers and facilities that haven’t signed a contract with your health plan. to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays 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 plan’s deductible or 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. Surprise medical bills could cost thousands of dollars depending on the procedure or service. You’re protected from balance billing for:

Emergency services: If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). 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.
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 can 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 types of 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 out-of-network care. You can choose a provider or facility in your plan’s network. When balance billing isn’t allowed, you also have these protections:

You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
Generally, your health plan must:
- Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
- Cover emergency services by out-of-network providers.
- 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.
- Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

If you think you’ve been wrongly billed, contact the Center for Medicare and Medicaid Services at (800) 985-3059. Visit cms.gov/nosurprises for more information about your rights under federal law.

Client’s Legal First Name:*

Client’s Legal Last Name:*

Client’s Date of Birth:*

GUARANTOR INFORMATION

The person that completes this document will be set up as the guarantor. This must be a parent, legal guardian, someone with a POA/delegation, or client that is aged 18 or older

Guarantor First Name*

Guarantor Last Name*

Guarantor Date of Birth*

Your relationship to the client.*

Phone Number*

Mailing Address*

Street Address City State ZIP Code

Guarantor Employment Status*

Guarantor Employer*

MYCHART ACCESS

Would you like to be set up with Proxy access through MyChart for your child? This is the easiest way to message your child's Catalpa providers, request Catalpa medication refills, and schedule or cancel therapy and psychiatry appointments. If you do not have your own MyChart through ThedaCare, an email will be sent to you with an activation code and instructions on how to sign up for MyChart so you can obtain Proxy access.*

My email address for MyChart instructions

An email will not be sent if you already have a MyChart account for yourself through ThedaCare. For assistance with accessing your current account, please call us.

Signature of Guarantor*

Signature of Parent/Legal Guardian (Guarantor)

Signature of Client (if age 14 or older)

Financial Agreement

INSURANCE INFORMATION