Thank you for choosing UrbanCare, LLC as your healthcare provider. We are dedicated to your health and medical care. A thorough understanding of your financial responsibility is an important element of your care and treatment. Please read this form carefully. Signature is required prior to any treatment.
Co-pays are due at the time of service. If co-pay is not paid, a $10.00 fee will be added. If you do not have insurance, payment is due in full at the time of service.
You are responsible for any co-payments, deductibles, and non-covered services. It is your responsibility to understand your insurance coverage and benefits. We suggest that you call your insurance prior to having services done so that you understand your benefits. You are required to bring your insurance card to your office visit, we cannot bill your insurance without your card. If insurance information is not available, you will be considered self-pay and responsible for payment at the time of service. Upon request, our staff will be happy to assist you in obtaining the specific terms of your health insurance policy. You are responsible for notifying Urbancare of any changes to your insurance and providing your new card. Failure to update Urbancare with insurance changes may result in patient responsibility for the entire bill. We do not bill workman’s compensation or auto claims. Laboratory charges denied by insurance due to maximum benefits reached will be patient’s responsibility
SERVICES RENDERED TO MINORS:
In case of divorce or separation the parent authorizing treatment for a child will be responsible for those subsequent charges.
Your balance is due in full within 30 days of statement. Any balance not paid in full must be pre-approved by our billing department. Balances not paid in full will incur a $20.00 rebilling fee each month there is a balance. Failure to pay your bill in full or to make payment arrangements will result in your account being sent to collection (additional collection fees will apply, not to exceed 50% of the unpaid balance). Any checks returned for non-sufficient funds will incur a $25.00 charge. Initiation of collection proceedings may result in discharge from the practice.
Patients requesting their medical records are required to sign an authorization. Medical record copying fees under Illinois State law will apply.
If you should need to cancel your appointment, please contact us at least 24 hours in advance of your appointment time. If you do not show for an appointment or do not provide 24-hour cancellation notice, we will assess a $50 fee to your account. This missed appointment fee will increase to $100 on your fourth occurrence and all subsequent occurrences.
EXCESSIVE RESCHEDULING OR CANCELING:
After four appointments cancelled or rescheduled within a year will receive a warning. After their fifth appointment will be charged a $100. Patients who are repeatedly cancelling appointments, late, or are continuously failing to keep their appointments, may be discharged from the practice.
Televisits (virtual visits), telephone visits, and virtual check-ins are offered by UrbanCare. UrbanCare will bill your insurance for these visits, however, if they are not covered it is patient responsibility. Also, after hour telephone calls may result in a telephone consult fee starting at $50.00 which is not billed to your insurance and is patient responsibility.
I HAVE READ AND UNDERSTAND URBANCARE, LLC. FINANCIAL POLICY. I UNDERSTAND AND AGREE TO THIS FINANCIAL POLICY.
Signature of Patient or Guardian/Responsible Party for Minor
– Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date of Birth
If you are not the patient, please specify your relationship to the patient