DBA THC Health Centers, LLC
Acknowledgment of Responsibility
To our valued Horizon patients:
We are glad to accept Horizon insurance, however we are non-participating with Horizon. This simply means that Horizon will send all correspondence and payments to you instead of us.
Horizon instructs providers request patients to pay the bill in full at the time services are rendered, however, we do not want to put that financial burden on our patients. As a professional courtesy, we will submit to your insurance for you. When you receive their correspondence and/or payment, you will then turn over all that you have received to our office.
Please note that we provide such services to our patients as long as the following is agreed upon by initialing below:
1. I understand that I may be receiving the correspondence/checks from Horizon. I agree to give the payment AND copies of ALL correspondence to the office within 7 days of receiving the information myself.
2. I understand that I need to turn over copies of ALL correspondence I receive, even if there is no check attached. I have been advised that Horizon explanation of benefits may show other valuable information such as deductibles applied and other denials which my provider may need for appeal/resubmission.
3. I understand that as a non-par provider, Horizon may only provide limited information about claims payment. If there is a claim that Horizon is stating was processed to me which I insist was not received, I understand that I may need to have a conference call with my carrier, your billing office and myself.
4. I have been advised of the credit card debit program.
As a courtesy to our new Horizon patients, we will submit insurance claims on your behalf for processing. However, instead of checks, Explanation of Benefits (EOB'S) and other correspondence being sent to our office from Horizon, all correspondence including checks will be forwarded directly to the plan holder, which is most cases would be you the patient.
In the event that you are not the plan holder it is your responsibility to locate the plan holder and acquire the checks and turn them over to our office. It is not our responsibility to neither locate the plan holder nor acquire the checks from them.
I, , choose to turn over all checks to the office instead of having my credit/debit card charged. I understand that it is my responsibility to obtain ALL checks and correspondence and turn them over to THC as soon as I receive them. I further understand that is not THC's responsibility to obtain nor acquire the checks for me.
In our "Acknowledge of Responsibility" form, we stated that in the event checks are not turned over to this office within 2 weeks of being issued from Horizon, with your authorization we will charge your credit card for the entire office visit.
I, , authorize Transformational Health Centers (dba THC Health Centers) to debit my credit card under the following circumstances, in the event the provider's office is advised that Horizon has processed a claim (s) to the plan holder, of which I am insured, over 2 weeks ago.
My Credit card information is as follows (optional):
I understand that my credit card information will be kept in a secure location. I also understand that if my credit card has been debited, the office is responsible for sending me a receipt for the transaction. Should I close the above account I agree to contact the office immediately. I also understand that if my credit card is declined I will be charged a $35 processing fee.