Patient Financial Responsibility

FINANCIAL RESPONSIBILITY AGREEMENT

Plume Health, P.C., a Virginia professional corporation and its affiliated medical groups (collectively, “Plume”) are committed to providing the best quality healthcare services (“Services”). This Financial Responsibility Agreement (“Agreement”) outlines your financial responsibility in relation to receipt of the Services from Plume.

PAYMENT OPTIONS

Plume accepts certain insurance plans in certain states. Please let Plume know if you have medical insurance that you plan to use for payment of the Services. Plume also offers a self-pay option for the Services. Please see the “Self-Payment of Services” section below for information on self-pay options

OPTION A: INSURANCE

As a courtesy to its patients, Plume is pleased to assist in the submission of medical insurance claims to insurance companies for payment. Currently, Plume participates with and bills commercial health plans. Plume does not participate with any federal health care providers or any health plan not identified herein.

To the extent you have insurance, by clicking “I have read and agree…” while creating your membership, you understand and acknowledge that:

Your medical insurance policy, if any, is a contract between you and your insurance company. It is your responsibility to know your benefits, and how they will apply to payment for the Services.
It is your responsibility to confirm that the provider that you see at Plume is a participating provider under your medical insurance policy.
Your insurance company may not cover 100% of the costs and fees associated with the Services, and you will be responsible for payment of any remaining balance due for the Services, including without limitation, for paying co-payments, deductibles, and any other costs and fees associated with the Services you receive that are not fully (or at all) covered by your insurance company.
It is your responsibility to provide Plume with appropriate and current medical insurance information, and to notify Plume immediately upon any change in your medical insurance coverage to ensure efficient claims billing and payment. In the event that you fail to provide all necessary and current medical insurance information, you understand that your insurance company may deny payment of claims relating to the Services, and you understand that you may be 100% responsible for the costs and fees associated with the Services.
It is your responsibility to have obtained any and all necessary referrals and authorizations required prior to receiving the Services from Plume. If your insurance company requires a referral and you do not have one, then you understand that you will be responsible for all the costs and fees associated with the Services you receive.
If your medical insurance requires a co-pay, the co-pay is required at the time the Service is rendered.
To the extent you have insurance, by [signing/clicking “I agree”] below, you further hereby assign all your right, title, and interest in any and all health insurance or other health care benefits payable to you or on your behalf by any insurance company, including Medicare, private insurance and any other health plan for the Services rendered by Plume and authorize payment of such benefits which are payable to you under the terms of your medical insurance policy to be paid directly to Plume for the Services rendered. The assignment and authorization will remain in effect until revoked by you in writing. Further, you authorize the release of pertinent information necessary to process your medical claim. You also authorize direct payment to Plume of all insurance benefits payable to you for such medical treatment. In the event an insurance payer pays you directly, you agree to immediately pay such amounts to Plume.

OPTION B: SELF-PAYMENT OF SERVICES

Services provided by Plume that are not covered by medical insurance are 100% self-pay by our patients.

By clicking “I have read and agree…” while creating your membership, to the extent applicable, you understand and acknowledge that:

You are electing to purchase the Services on a self-pay basis either because you do not have medical insurance or your medical insurance does not cover the selected Services.
You have been given a choice of the Services provided by Plume, along with their costs.
You have selected the Services, and you are willing to accept full financial responsibility for payment of the Services.
You have selected the Services for purchase from Plume on a self-pay basis. In other words, to the extent you have medical insurance, you have Plume to treat your purchase of the Services as if you were an uninsured patient because these Services are not covered by your medical insurance, and you therefore agree to be 100% responsible for full payment of the listed price of the Services as set forth in the Fee Schedule.