Patient Financial Agreement

When visiting the health center for treatment, patients (or their parent or guardian) will be asked to sign an acknowledgement of payment practices and potential late payment charges. By signing, patients or their guardians indicate agreement to the following:

• I accept financial responsibility for any non-covered or denied charges and for co-pays, deductibles, and co­insurance not covered by my insurance including those for durable medical equipment. Durable medical equipment may include braces, splints, orthotics, crutches, TENS units, or other types of rehabilitative equipment.
• I authorize release of any medical or other information necessary to process the claim.
• I authorize payment of my insurance benefits directly to the Sindecuse Health Center.
• Charges for lab tests sent to and billed by the external reference lab are my responsibility. I authorize Sindecuse Health Center to send any insurance information I provide to the reference lab.
• It is my responsibility to know what my insurance covers and to ask questions prior to receiving service.
• If I do not have insurance I accept financial responsibility for all charges incurred. 
• I understand that Sindecuse Health Center charges late cancel and no show fees if I do not cancel an appointment within notification times outlined on the health center web site, or in reminder emails.
• Late payment charge: I understand and agree that if I fail to pay my account bill or any monies due and owing Western Michigan University by the scheduled due date, Western Michigan University will assess monthly service charges on the past due portion of my account until my past due account is paid in full.
• Collection agency fees: I understand and agree that if I fail to pay my account bill or any monies due and owing Western Michigan University by the scheduled due date, and fail to make acceptable payment arrangements to bring my account current, Western Michigan University may refer my delinquent account to a third party collection agency. I further understand and agree that I am responsible for paying the collection agency fee, which may be based on a percentage at a maximum of thirty-nine percent (39%) of my delinquent account, together with all costs, and expenses, including reasonable attorney's fees and court costs, necessary for the collection of my delinquent account. Finally, I understand and agree that my delinquent account may be reported to one or more of the national credit bureaus.

MEDICARE PART B RECIPIENT AUTHORIZATION: I request payment of authorized Medicare benefits be made on my behalf for services furnished me by Sindecuse Health Center. I authorize Sindecuse Health Center to release to the Center for Medicare and Medicaid Services or its agents any information needed to determine these benefits or the benefits payable or related services.

Agreement valid for one year from date signed.