Please read the following information prior to completing the Patient Questionnaire in the Patient Portal in which you will provide financial/billing information.
You will be asked to sign a copy of this form to confirm your consent(s), and to confirm your financial information when you check in for your appointment. If needed, you will be able to review your financial information prior to signing.
At the time of your visit you must bring in a government issued picture ID and your insurance cards.
Release of Benefits and Information
I consent for medical treatment, and I confirm that the insurance information listed on this form to be complete and accurate. I authorize my insurance benefits to be paid directly to the doctor. I am financially responsible for any balance due. I authorize the doctor or the insurance company to release any information required for this claim.
Financial Arrangements Policy
We are dedicated to providing outstanding medical care to our patients. We do our utmost to be helpful and informative in the area of financial obligation. If you ever have any questions concerning this policy, or your part in it, please ask. Please read the following explanation of our financial arrangements policy. The payment options will be listed on the questionnaire. You can select the payment option that would be the best for you.
Patients Without Insurance
If you do not have insurance, we expect payment in full at the time of service. For your payment convenience, we accept cash, check, money order, Visa/Mastercard, Discover and American Express. You may also choose to leave your signature and credit card number on file; with your authorization, we will charge your card monthly for your personal account balance. Should your account balance become delinquent and assigned to a collection agency, you will be discharged from the clinic and we will no longer provide care for you.
Good Faith Estimate Notification
Valley Medical Care is committed to providing patients who have no insurance coverage or choose not to use their insurance coverage with a Good Faith Estimate. The Good Faith Estimate shows the costs of medical items and services that are reasonably expected for your health care needs. The estimate is based on information known at the time the estimate was created and can be obtained by calling or visiting our office. If you choose to have care performed by Valley Medical Care, a written copy of the Good Faith Estimate will be provided to you.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
If you are billed for more than the Good Faith Estimate provided, you have the right to dispute the bill.
You may contact Valley Medical Care to let them know the billed charges are higher than the Good Faith Estimate you received. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is a payment plan or financial assistance available.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS) if the bill you receive is more than $400 over the amount listed on the Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059.
Patients With Insurance
Valley Medical Care is an in-network provider with Premera Blue Cross, EBMS, Tricare, Medicare, Medicaid and Triwest. Due to the fact that insurance policies can be confusing and differ widely in coverage, we will do our best to assist you. We will prepare and file your insurance claims for you. We will also wait up to 40 days for their portion of the billed charges. Under this arrangement, you are responsible for paying your co-pay, any non-covered portions, and any deductible you have yet to cover. For your payment convenience, we accept cash, check and money order, Visa/MasterCard, Discover and American Express. You may also choose to leave your signature and credit card number on file; with your authorization, we will charge your card monthly for your personal account balance. Bear in mind that you are responsible to know and understand your insurance policy and are ultimately responsible to pay Valley Medical Care for your entire account balance regardless of your insurance company’s payment schedule. Should your account balance become delinquent a per month billing charge may be assessed to your account. If the delinquency continues for 90 days, your account will be assigned to a collection agency, you will be discharged from the clinic and we will no longer provide care for you.
We file claims to your insurance as a courtesy to you. You are expected to pay your deductible and copays at the time of service. If we have not received payment from your insurance within 60 days of the date of service, you will be expected to pay the balance in full. You are responsible for all charges regardless of insurance status.
If you need assistance please contact our billing department between 8:00am and 4:00pm M-F at 907-586-2482.
No Surprise Act
What are surprise medical bills?
If you have health insurance and get care from an out-of-network provider or at an out-of-network facility, your health plan may not cover the entire out-of-network cost. This can leave you with higher costs than if you got care from an in-network provider or facility.
In the past, in addition to any out-of-network cost-sharing you might owe (like coinsurance or copayments), the out-of-network provider or facility could bill you for the difference between the billed charge and the amount your health plan paid (unless banned by state law). This is called “balance billing.”
An unexpected balance bill from an out-of-network provider is called a surprise medical bill.
What are the new protections if I have health insurance?
If you get health coverage through your employer, the Health Insurance Marketplace®, or an individual health insurance plan you purchase directly from an insurance company, these new rules will:
Ban surprise bills for emergency services, even if you get them out-of-network and without approval beforehand (prior authorization).
Ban out-of-network cost-sharing (like coinsurance or copayments) for all emergency and some non-emergency services. You can’t be charged more than in-network cost-sharing for these services, and any cost-sharing you pay counts towards your deductible and maximum out-of-pocket limits for the policy year.
Ban out-of-network charges and balance bills for supplemental care (like anesthesiology or radiology) by out-of-network providers who work at certain in-network facilities (like a hospital or ambulatory surgical center).
Require that health care providers and facilities give you an easy-to-understand notice explaining that getting care out-of-network could be more expensive, and your options to avoid balance bills. You’re not required to sign this notice or get care out-of-network.
If you have a health insurance plan with an out-of-network benefit, like a Preferred Provider Organization (PPO), you can choose to go to an out-of-network provider. But you can’t be billed more than in-network cost sharing amounts for items or services provided by an out-of-network provider at in-network facilities unless you consent to getting care out-of-network by signing a notice and consent form.
For more information about the No Surprise Act, visit: https://www.cms.gov/nosurprises/consumers
Electronic Medication History and Insurance Prescription Benefits
Our electronic medical record program enables us to review your electronic medication history (prescriptions you have filled) to help us verify the medications you are currently taking. This aids the provider in making appropriate choices for treatment.
We can also verify your prescription medication coverage so that we may prescribe appropriate medications that will be covered by your insurance plan.
Your consent is needed for us to obtain this information. You can select to give or withhold consent on the questionnaire.
Acknowledgement of Receipt of Notice of Privacy Practices for all Health Information
You have the following options for viewing our Notice of Privacy Practices. You may obtain a paper copy from the office, you can read/print a copy from our website (www.valleymedicalcare.com), or you may read a posted copy at our office. Your signature on this form will be your acknowledgement of receipt of this document in one of the available formats.
Valley Medical Care participates in a Hospitalist program while treating our patients who may be admitted to Bartlett Regional Hospital for care or observation. As a patient of Valley Medical Care, you agree to medical care by any of our physicians/nurse practitioners acting in the hospitalist role. If you have any adverse feelings about treatment from any specific VMC physician/nurse practitioner, you should seek primary care with another primary care practice. By signing this agreement, you agree to treatment by any of our practitioners in the hospital setting.
All patients of Valley Medical Care become inactive after 3 years without appointments or treatment. If you fall into an inactive status and want to resume care with VMC, you may be asked to fill out a “New Patient Request Form”.