Blessed Hands IV Hydration Wellness Clinic LLC

Financial Responsibility & Insurance Acknowledgment Agreement

Patient Name:

Date of Birth:

Date:

At Blessed Hands IV Clinic, we strive to provide high-quality wellness and medical infusion services while helping patients utilize any available insurance benefits when appropriate. Please carefully review and sign the following acknowledgment regarding financial responsibility and insurance billing.

Insurance Coverage Acknowledgment

I understand that verification of insurance benefits is not a guarantee of payment or coverage. I understand that my insurance company may deny payment in whole or in part for services rendered at Blessed Hands IV Clinic.

I understand that many infusion-related services, supplements, hydration therapies, wellness treatments, and associated supplies may not be covered benefits under my insurance plan, even when medically recommended or prescribed.

I understand that I am ultimately financially responsible for any balance not paid by my insurance carrier, including but not limited to deductibles, co-insurance, co-pays, non-covered services, denied claims, and services determined by my insurance company to be not medically necessary.

Services and Items That May Be Billed

I understand that charges submitted to insurance and/or billed to me may include, but are not limited to:

Office visit or evaluation services

IV infusion administration services

IV hydration therapy

IV infusion pump administration

Normal saline and IV solutions

IV vitamin and mineral additives/supplements including but not limited to magnesium, potassium, taurine, zinc, vitamin C, B-complex vitamins, amino acids, glutathione, and other nutritional or therapeutic additives

Medical supplies used during treatment including but not limited to IV catheters, additional IV catheter attempts if needed, IV tubing, saline flushes, syringes, alcohol prep pads, gloves, Tegaderm dressings, tape, gauze, bandages, and sharps disposal materials

Injection administration fees

Medication preparation and handling fees

Observation or monitoring services when applicable

I understand that the exact charges billed may vary depending on the treatment provided, medical necessity, duration of infusion, supplies required, and clinical circumstances during my visit.

Financial Responsibility

I agree to pay all balances not covered or paid by my insurance company. I understand that any unpaid balance may be billed to me at the clinic’s established rates.

I understand that any estimate provided by the clinic is not a guarantee of final insurance payment or patient responsibility.

I authorize Blessed Hands IV Clinic to bill my insurance carrier on my behalf when applicable and to release necessary medical information required for claim processing.

Cash Pay Option

I understand that Blessed Hands IV Clinic may offer self-pay or cash-pay pricing for certain services. I understand that self-pay pricing may differ from standard billed charges submitted to insurance carriers.

I understand that if I elect self-pay services, payment may be due at the time of service unless other arrangements have been approved in writing.

Insurance Participation and Billing Discretion

I understand that Blessed Hands IV Clinic reserves the right, at its discretion and in accordance with applicable laws and payer contracts, to discontinue billing my insurance plan and require services to be provided on a self-pay basis.

I understand that certain services may not qualify for insurance billing and may automatically be considered self-pay services.

Patient Responsibilities

I agree to provide accurate and current insurance information at each visit.

I understand it is my responsibility to notify the clinic immediately of any changes to insurance coverage, coordination of benefits, primary care provider assignments, referrals, or other healthcare providers involved in my care.

I understand that failure to provide accurate insurance information in a timely manner may result in denial of claims and financial responsibility for balances owed.

I agree to cooperate with any reasonable requests for information needed to process insurance claims or coordinate care.

Clinic Policies

I understand that abusive behavior toward staff, repeated failure to comply with clinic policies, repeated missed appointments, repeated unpaid balances, misuse of services, or failure to comply with treatment recommendations may result in dismissal from the clinic in accordance with applicable laws and continuity-of-care requirements.

I understand that medical treatment recommendations and insurance billing decisions are determined based on medical necessity, provider judgment, payer policies, and applicable regulations.

Acknowledgment

By signing below, I acknowledge that I have read, understand, and agree to the terms outlined in this Financial Responsibility & Insurance Acknowledgment Agreement. I understand that I am financially responsible for all services rendered that are not covered or paid by insurance. I further acknowledge and authorize the practice to send billing statements and related account communications to me electronically via email in accordance with HIPAA confidentiality standards. I understand that I may request a printed copy of my billing statement at any time if preferred.

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