We bill your personal insurance carrier solely as a courtesy to you. We require that you pay the estimated amount of what you owe (“patient responsibility”) at every appointment. It is not a guarantee of the amount you owe, it is only an estimate. Furthermore, if you have virtual visits coverage, Origin will bill virtual visits at the same rate as in-person visits because that is how they are commonly reimbursed; however, we cannot guarantee it. You are responsible for your bill, so if you would like to be certain of your coverage and patient responsibility, we encourage you to verify with your insurance company prior to your appointments.
In the event that your insurance company requests a refund of payments made to us, you may be responsible for the amount of money refunded to your insurance company. If any payment is made directly to you by the insurance company for services billed by us, you recognize an obligation to promptly remit the payment(s) to us. If formal collections procedures become necessary, you will be responsible for additional costs incurred.
We will review your estimated insurance benefits with you at the time of your visit. Your benefits are quoted to us by your insurance carrier, and we assume no liability for any errors made by your insurance carrier in this estimate. We will attempt to obtain authorization for additional appointments necessary once insurance coverage for the initial appointments ceases (including steps necessary to appeal a denial); however, this does not guarantee that your insurance will accept the request to authorize additional appointments. You are also responsible for keeping track of appointments covered in your policy. If your insurance authorizes a request for additional appointments beyond the initial appointments covered in your policy, there will be no change from your financial responsibility outlined in your original policy.
Balance due, self-pay & cash rates
You will be considered a self-pay patient and responsible to pay our cash rates, and your balance owed will due in full, if your:
- Claims get denied, for any reason
- Insurance is inactive
- Insurance company doesn’t process your payment within 60 days
- Insurance company does not authorize visits
- Insurance company does not verify your eligibility or benefits
- Treatment exceeds the coverage of your insurance policy
- Insurance does not cover our services
- Insurance is out of network
- Prescription (Rx), referral or Plan of Care is not provided in timely manner
Consent to store your credit card on file and charge balances that are due
You authorize Origin to process your credit card as “Card on File”. You understand this authorization will remain in effect until (i) the expiration of the credit card account, or (ii) you revoke your authorization of this form by submitting a written request to Origin. You understand your credit card can be used to cover any expense incurred at Origin including without limitation: copays, coinsurance, deductibles, outstanding treatment charges, missed or late cancellation charges, equipment, and supplies.
Receiving care from providers outside of your insurance plan provider network usually will result in higher out-of-pocket costs for you. Origin encourages you to contact your insurance plan to confirm that Origin is a provider within your plan’s network before services are rendered.
Each returned check will incur a $30 returned check fee and an alternative form of payment will be required for all subsequent payments.