Thank you for choosing REVIVE Center for Health & Wellness as your health care provider.

Please review our financial policy.

PAYMENT IS DUE AT TIME OF OFFICE VISIT

We Accept Cash, Checks, Venmo, Cash App, Visa, MasterCard and American Express

Insurance Policies: Your insurance policy is a contract between you and your insurance company. Professional care is provided to you, our patient, and not to an insurance company. Thus, the insurance company is responsible to the patient and the patient is responsible to the provider. We will gladly process your claim, but we require your estimated portion to be paid at the time of service. To do so, we require your complete insurance information. In the event we do accept assignment of benefits, please know that the balance of your bill is your responsibility, whether your insurance company pays or not. Regarding insurance plans in which we are a participating provider, please understand that we do require payment of co-pays and deductibles prior to treatment. Once the insurance carrier has returned remittance and has determined your balance, the credit card on file will be charged.

High Deductible Health Plan: AHigh Deductible Health Plan (HDHP) is a health plan product that combines a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) with traditional medical coverage. Patients enrolled in a high deductible health plan are required to remit an appropriate co-payment of $100.00 upon arrival at the office for the appointment. After the practice receives payment from the insurance company and discount adjustments have been posted, the credit card on file will be charged.

Non-Participating Carriers: You are responsible for all charges if we do not have a participation agreement with your insurance carrier. If you provide our office with the necessary information needed to properly bill, we will submit the claim on your behalf. You are responsible for following up with your insurance carrier for unpaid claims and/or appeals. You are responsible for all deductibles, co-pays, and non-covered charges. Once the insurance carrier has returned remittance and has determined your balance, the credit card on file will be charged.

Self-Pay: If you are uninsured, you are responsible for remitting payment in full at the time of service.

Payment By Check: The office accepts payment by check. There is a $30.00 fee for returned checks.

Appointment (Late arrival or cancelation/No-show): Patients will receive text/voice/email reminders of their appointment date and time. If you need to cancel or reschedule your appointment, please notify the office 24 hours prior to your appointment. There will be a $50.00 charge to the patient for a late arrival (10 minutes past appointment time), no-show or late cancelation.

Insurance Authorization and Assignment:I request that payment of authorized insurance benefits be made on my behalf to REVIVE Center for Health & Wellness for any services provided. I hereby authorize to release any medical information necessary to process my claim. I permit a copy of this authorization to be used in place of the original. The authorization may be revoked either by me or my insurance company at any time in writing.

If you are unable to pay your balance, please contact our office at 860.375.2227 to discuss a payment plan.If you need further explanation of any of the above policies, please contact the office.

I have read the financial policy. I understand and agree to this financial policy.

Patient Name: Date

Patient/ResponsibleParty Signature:

FOR MEDICARE PATIENTS ONLY:I request that payment of authorized Medicare benefits be made on my behalf to the provider for any services furnished to me by the provider. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits payable for related services.

Patient Name: Date

Patient/ResponsibleParty Signature:

MEDIGAP:Name of Medicare Supplement(MEDIGAP) Insurer:
I request that payment of authorized MEDIGAP benefits be made on my behalf to the provider for any services furnished me by the provider. I authorize any holder of medical information about me be released to the above named MEDIGAP insurerin order to determine payable benefits for related services.

Patient Name: Date

Patient/ResponsibleParty Signature:

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