PATIENT CONSENT AND FINANCIAL AGREEMENT
CONSENT FOR TREATMENT AND CARE. I consent to the healthcare services offered to me at Logan Health facilities and clinics and by approved Logan Health providers. (“Healthcare Services”). Healthcare Services include: telehealth visits, inpatient care, outpatient care, emergency room services, diagnostic procedures, medical transportation, nursing care, and medical equipment. I understand that Logan Health cannot guarantee a certain outcome from the Healthcare Services that I receive. If I am unable to sign this agreement myself, I may authorize a person to sign on my behalf. An informed consent is not needed in the event of an emergency situation.
AGREEMENT TO PAY. I and/or any person, parent, or guardian (“Guarantor”) in charge of my medical bills, agrees to pay Logan Health for the charges related to my Healthcare Services, minus any reductions to which I am entitled. I am aware and agree that: (1) I may receive a separate bill from independent, non-Logan Health employed providers, (2) this Agreement prevails over any conflicting terms and conditions in any other contract or plan to which I claim to be a party or a beneficiary, (3) my Health Plan may decide that the Healthcare Services I receive at Logan Health are not covered and that I will be liable for paying for those Healthcare Services, and (4) this Agreement is governed by the laws of the State of Montana.
FINANCIAL ASSISTANCE. Logan Health offers a financial assistance program. For more details and to
apply online, please visit www.logan.org and click on the Financial Assistance links.
PAYMENT. Guarantor(s) agree to pay Logan Health: (1) at the time Healthcare Services are provided, (2) according to Logan Health billing statements, and/or (3) according to an agreed upon payment arrangement made between Logan Health and the Guarantor(s). If the Guarantor(s) fails to make any scheduled payment when due, I understand and agree that Logan Health: (1) may insist that I pay the entire balance at once, (2) partial payments will not be accepted as payment in full without a signed, written agreement between the Guarantor(s) and Logan Health, (3) Guarantor(s) will be held liable for all costs related to the collection of payment(s) and any related attorney fees, (4) Logan Health may assign past due accounts to collection agencies, and (5) payment owed to independent providers must be made according to their payment rules.
THIRD PARTY LIABILITY. If I receive Heath Care Services in the event of an accident and a third-party is or could be liable for some or all of the charges, I agree that the Guarantor(s) is/are liable for the charges. Logan Health is permitted by Montana law to bill and recover the full amount of charges related to my Healthcare Services from any responsible third-party. Logan Health may (and is sometimes required to) bill a third-party prior to submitting a bill to any federal, state, or private health insurance/health benefit plan (“Health Plan Payor”) that provides coverage for my Healthcare Services. Guarantor(s) will not be liable for any amount in excess of the portion of the charges that I am held responsible to pay. Logan Health may decide who and how to recover payment for charges for the Healthcare Services given to me. Seeking payment from one person or entity will not create an assignment or waiver of the right to seek recovery from any other party, including myself, other persons, or any other payor/insurer.
ACCOUNT OVERPAYMENTS. If I have overpaid my account by $5.00 or less, I agree that the amount is too small to refund and the amount will be written off. If I have overpaid my account by more than $5.00, I agree that the overpaid amount will be applied to any other account balances for which I am responsible. If there are no other account balances for which I am responsible, a refund check will be issued to me through the mail. If the refund check is undeliverable and returned to Logan Health after 3 years, then the overpayment amount will be sent to the Montana Department of Revenue in accordance with Montana law.
APPOINTMENT OF LOGAN HEALTH AS AUTHORIZED REPRESENTATIVE. Without altering this
agreement, I authorize and appoint Logan Health to: (1) submit a claim or appeal; and (2) accept, bargain, or deposit a payment. Logan Health will provide these services on my behalf by reaching out to any Health Plan Payors and other liable third-party (known as “Responsible Third Parties”) providing coverage for or payment for any charges related to Healthcare Services that I receive. Logan Health will direct those Health Plan Payors and Responsible Third Parties to make payment(s) directly to Logan Health. I am aware of and agree that: (1) Logan Health is not required to submit a claim or appeal for payment to anyone other than the Guarantor(s); and (2) Logan Health may choose to submit a claim or appeal to any Health Plan Payors or Responsible Third Parties. This authorization is limited to the right to submit a claim or appeal, accept, bargain or deposit payment on my behalf from any health plan, Insurer, or Responsible Third-Parties. Logan Health is not bound by any obligations I have with regard to the agreement I have with my health plan, insurer, Responsible Third-party, or any other theories of coverage or liability. I agree to allow Logan Health to notify my health plan, insurer, or Responsible Third-Parties. This authorization and appointment will remain valid and can only be voided in writing.
HEALTH INFORMATION EXCHANGE. The Health Information Exchange (HIE) is the electronic sharing of my medical information with approved Logan Health and self-employed providers. This also includes sharing medical information with my health plan or insurer.