Terms of Services
TRANSACTION FEES
Effective 02/15/2023, our vendors will be adding a fee for all credit card
transactions.
TEXT AND EMAIL COMMUNICATION NOTICE
You hereby expressly consent to the practice sending you any type of
electronic message (including, without limitation, other commercial
communications, informational communications, and electronic notices, and
updates), whether through the site or by telephone, e-mail, online social
media, or any other electronic media means or forms. By giving such consent,
you agree that no such communication shall violate the telephone consumer
protection act, the CAN-SPAM Act or any other applicable laws, rules, or
regulations. Voice, message, and data fees, rates, charges, and/or taxes may
apply to you, and you are responsible for payment of the same. You are not
required to grant the foregoing consent as a condition for the use of the site
and can opt out of electronic communications at any time.
EMERGENCY CONTACT AGREEMENT
Patients will provide the Practice with contact information for the Patient's
guardian(s) or next of kin, which information will be used to contact the
Patient's /guardian(s) or next of kin (as the case may be) in case of
emergency or in cases where it is deemed necessary for the safety, security
and/or wellbeing of the Patient or other community members, or where the
Patient is otherwise incapacitated. Regardless of the Patient's age, the
Patient will not make any objection to or seek to hold the Practice liable
whatsoever for such contacting of the Patient's guardian(s) or next of kin (as
the case may be). This Agreement covers any previous emergency contacts or any
future contacts that are to be provided and is applicable regardless of
whether the Patient notifies us of the contact verbally or in writing.
FINANCIAL POLICY
APPOINTMENTS
- Copayments. Copayments for clinic visits are due at the time of service. If
you are unable to make your copayment at the time of service, Sussex Pain
Relief Center reserves the right to reschedule your appointment until a time
that you can make your copayment. Payment for any outstanding balance is due
at the time of your appointment.
- Missed Appointments and Late Arrivals. If you are more than 15 minutes late,
we may reschedule your appointment. If you are more than 60 minutes late, or
if you do not show up to your appointment, you will be responsible for a
missed appointment fee. Missed office visit appointments are subject to a
$35 charge. Missed procedures are subject to a $100 charge. These charges
are your responsibility and will not be billed to any insurance carrier.
INSURANCE PAYMENTS
- Financial Responsibility. Your insurance policy is a contract between you
and your insurance carrier. You are ultimately responsible for
payment-in-full for all medical services provided to you. Any charges not
paid by your insurer will be your responsibility, except as limited by our
contract (if any) with your insurance carrier.
- Coverage Changes and Timely Submission. It is your responsibility to inform
us in a timely manner of any changes to your billing or insurance
information. There is a time limit within which Southern DE MMJ must submit
a claim on your behalf to your insurer. If Sussex Pain Relief Center is
unable to submit your claim within this period because we have not been
supplied with your correct insurance information, you will be responsible
for the charges.
- Self-Pay. If you do not have health insurance, or if your health insurance
will not pay for services rendered by Southern DE MMJ, you will be
considered a self-pay patient. Your charges will be based on our current
self-pay schedule. Self-pay patients are expected to make payment in full at
the time of service or at the time they are billed.
BENEFITS AND AUTHORIZATION
- Insurance Plan Participation. We participate in many but not all insurance
plans. It is your responsibility to contact your insurance company to verify
that your assigned physician participates in your plan. Out-of-network
charges may have higher deductibles and copayments.
- Referrals. Referral and prior authorization requirements vary widely among
insurance carriers and plans. If your insurance carrier requires a referral
for you to be seen by Southern DE MMJ, it is your responsibility to be aware
of this fact and to obtain this referral.
- Prior Authorization and Non-Covered Services. Southern DE MMJ may provide
services that insurance plans exclude or require prior authorization to pay
for. If insured, it is ultimately your responsibility to ensure that
services provided to you are covered benefits authorized by your insurer.
Southern DE MMJ, as a courtesy to our patients, makes a good faith effort to
determine if services we order are covered by your insurance plan, and, if
so, whether prior authorization for treatment is required. If we determine
that a prior authorization is required, we will attempt to obtain such
authorization on your behalf.
- Out-of-Network Payments. If we are not part of your insurance carrier's
network (out-of-network) and your insurance carrier pays you directly, you
are solely responsible for payment and agree to immediately forward the
payment to Southern DE MMJ.
ACCOUNT BALANCES AND PAYMENTS
Refill requests will only be honored if it's made during your follow-up
visits. No refill requests will be honored if they're made in between
follow-up visits. It is highly recommended that patients bring prescription
bottles of medication that has been ordered by our office to each follow-up
visit in-person. During telehealth visits, patients can line up the medication
bottles on a table.
Please be advised that it is the patient's responsibility to notify providers
at the time of their visit that they need a refill on their medication.
- Reassignment of Balances. If your insurance company does not pay within a
reasonable time, we may transfer the balance to the patient, so they are
your sole responsibility. Please follow up with your insurance carrier to
resolve non-payment issues. Balances are due within 30 days of receiving a
statement.
- Collection of Unpaid Accounts. If you have an outstanding balance over 120
days old and have failed to make payment arrangements (or become delinquent
on an existing payment plan), we may turn your balance over to a collection
agency and/or an attorney, which may result in reporting to credit bureaus
and/or legal action. Southern DE MMJ reserves the right to refuse treatment
to patients with outstanding balances over 120 days old. You agree to pay
Southern DE MMJ for any expenses we incur to collect on your account,
including reasonable attorneys' fees and collection costs.
- Returned Checks. Returned checks will be subject to a $38 returned check
fee.
- Refunds. Refunds for overpayment are made only after there has been full
insurance reimbursement for all medical services on your account. Please
submit a written refund request and allow four to six weeks for your request
to be processed.
- Statements. Charges shown by statement are agreed to be correct and
reasonable unless protested in writing within thirty (30) days of the
billing dates.
REFILL POLICY
Refill requests will only be honored if it's made during your follow-up
visits. No refill requests will be honored if they're made in between
follow-up visits. It is highly recommended that patients bring prescription
bottles of medication that has been ordered by our office to each follow-up
visit in-person. During telehealth visits, patients can line up the medication
bottles on a table.
Please be advised that it is the patient's responsibility to notify providers
at the time of their visit that they need a refill on their medication.