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Please read the information below and fill out the form at the bottom of this page to use our financial services, or download the form here to fill out a hard copy.

Thank you for choosing Generation Care as your therapy provider. We are committed to providing the best possible care and service. Your clear understanding of our financial policy is important to our professional relationship.

We must emphasize that as a medical care provider, our relationship is with YOU, our patient, not with your insurance company. We cannot accept the sole responsibility of managing your claims with your insurance companies or any other persons. While the filing of your insurance claims is a “Courtesy” that we extend to our patients, all charges are your responsibility from the date of the services rendered.

Your health insurance is a contract between you, your employer, and the insurance company. Generation Care is not a party to that contract. We do not have access to the same information that you do. It is very important that you understand the provisions of your policy. We cannot guarantee payment on any claim. If your insurance company pays only a portion of the bill or rejects your claims, any contact or explanation should be made to you, the policyholder. Our priority is your care. We will provide your insurance company with any documentation and medical records they require…at no charge to you.

Our fees are based on national and regional comparative data, and we charge the lowest fees in the area. In addition, we are contracted with many insurance companies, and we are obligated to accept their fee schedule despite the fees set by our clinic. If your insurance company denies your claim we are not obligated to hold to the contracted amount; however, Generation Care will match the fee set by your insurance carrier. The patient is responsible for payment in full within a reasonable time…regardless of the status of the claim with your insurance company.

Even though an insurance claim has been filed, you will receive a monthly statement if your account has a balance due. We cannot accept responsibility for negotiating a settlement on a disputed claim. We realize that temporary financial problems may affect payment on your account in a timely fashion. If you experience such problems it is your responsibility to contact our financial coordinator to make the necessary arrangements for payment. A $25.00 late fee will be added to any account not receiving payment within 30 days of statement. Generation Care, PLC gladly accepts Cash, Check, Visa, and MasterCard for your convenience. Returned checks are subject to a $25.00 service fee and must be resolved before continuing treatment.

Co-pays are due at the time of service.

Thank you for understanding our financial policy. Please let us know if you have any questions.

1. Release of Personal Health Information

I AgreeI herby authorize Generation Care, PLC to release personal health information (PHI) within legal limits of the Health Information Portability and Accountability Act (HIPAA) of 1996 to:

  • Any third party responsible of paying or overseeing my medical care, including consulting physicians or hospitals.
  • Any outside peer review or auditing agency engaged by a third party payer.
  • To any person I have designated as my agent and/or patient advocate to act for me as permitted by state and federal law.
  • I understand that I may receive a progress note for delivery to my physician directly, and I assume all responsibility for doing so, including protecting my own privacy.

2. No show and Cancellation Policy

I AgreeI agree to contact Generation Care, PLC in the event that I am unable to attend my scheduled appointment. If I do not call or contact Generation Care, PLC to cancel my appointment and fail to attend, I will be charged a $35.00 No-Show fee per missed appointment. A $35.00 fee will be charged to you for any appointments not cancelled by 5:00 PM the day preceding your appointment. Generation Care, PLC reserves the right to waive the fees for extenuating circumstances.

3. Assignment of Insurance Benefits

I AgreeI authorize payment of medical benefits to Generation Care, PLC for all services rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance company. I hereby authorize Generation Care, PLC to release all information necessary to secure payment by my insurance provider. A photocopy of this assignment is to be considered valid as an original.