Assignment Of Benefits Form - Highland Clinic (Page 2 of 2) in pdf

Your Billing Rights - Keep this Notice For Personal Use

This notice contains important information about your rights and our responsibilities under The Fair Credit Billing Act.

Notify Us In Case of Errors or Questions About Your Bill

If you think your bill (statement) is wrong, or if you need more information about a transaction on your bill, write us (on a separate sheet) at the

address listed on your bill. Write to us as soon as possible. We must hear from you no later than 60 days after we sent you the first bill on which

the error or problem appeared. You can telephone us, but doing so will not preserve your rights.

In your letter, give us the following information:

Your name and account number.

The dollar amount of the suspected error.

Describe the error and explain, if you can, why you believe there is an error. If you need more information,

describe the item you are not sure about.

Your Rights and Our Responsibilities After We Receive Your Written Notice.

We must acknowledge your letter within 30 days, unless we have corrected the error by then. Within 90 days, we must either correct the error or

explain why we believe the bill was correct.

After we receive your letter, we cannot try to collect any amount you question, or report you as delinquent. We can continue to bill you for the

amount you question, including finance charges, and we can apply any unpaid amount against your credit limit. You do not have to pay any

questioned amount while we are investigating, but you are still obligated to pay the parts of your bill that are not in question. If we find that we

made a mistake on your bill, you will not have to pay any finance charges related to any questioned amount. If we did not make a mistake, you

may have to pay finance charges, and you will have to make up any missed payments on the questioned amount. In either case, we will send you

a statement of the amount you owe and the date that it is due.

If you fail to pay the amount that we think you owe, we may report you as delinquent. However, if our explanation does not satisfy you and you

write to us within ten days telling us that you still refuse to pay, we must tell anyone we report you to that you have a question about your bill.

And, we must tell you the name of anyone we report you to. We must tell anyone we report you to that the matter has been settled between us

when it finally is.

If we do not follow these rules, we cannot collect the first $50.00 of the questioned amount, even if your bill was correct.

If you have any questions about this notice or any aspect of the statement, please let us know.

FINANCE CHARGE:

The Finance Charge is computed as a periodic Rate of 1 ½ % per month which is an

Annual Percentage Rate of 18% applied to the 90 day balance after deducting payments

and credits appearing on this statement. For balances less than $50.00 there will be a

minimum Finance Charge of 50¢.

MANAGED CARE INSURANCE:

Highland Clinic has agreements with many Managed Care Insurance Companies and will abide by the agreement including Billing and

Collecting. The patient will be responsible for any co-pays, deductibles or non-covered services as directed by their Managed Care Plans.

It is the patient’s responsibility, before making an appointment, to confirm with your Managed Care Carrier as to whether or not Highland

Clinic physicians are providers and/or In-Network providers for their plan. The patient will be responsible for payment of their services if

Highland Clinic physicians are not providers or In-Network providers for their plan.

COMMERCIAL INSURANCE:

As a courtesy to our patients, Highland Clinic will file your insurance claims. Accurate insurance information and a copy of the insurance card must

be supplied by the patient. Although every attempt is made to help patients with filing for insurance benefits, the patient has final responsibility

for payment of services rendered. When your account has been paid in full, if an over payment occurs, Highland Clinic will refund the patient or

the insurance company within a reasonable length of time.

Services are payable upon date performed or upon receipt of monthly statement if credit has been established. If extended terms are required on

larger balances, the Credit Office will establish a payment schedule. For your convenience, we accept VISA and MASTERCARD.

In the event it becomes necessary to refer the account to an attorney or outside collection agency, you hereby agree to pay attorney fees of no less

than 33.33% of the amount due together with all court costs and judicial interest.

HIGHLAND CLINIC

A Professional Medical Corporation

1455 E. Bert Kouns Industrial Loop

Shreveport, LA 71105

318-798-4500

All Accounts Are Due In Full Upon Receipt Of Statement

Assignment Of Benefits Form - Highland Clinic Page 2

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