This Financial Responsibility Agreement (“Agreement”) is made between you, the undersigned individual or authorized representative (“Client”), and DreamQuest Home Healthcare Services, LLC (“DreamQuest,” “we,” “our,” or “us”). By receiving services from DreamQuest, you agree to the following terms and conditions regarding financial responsibility for the services provided.
1. Acceptance of Financial Responsibility
1.1 You agree to be financially responsible for all services provided by DreamQuest Home Healthcare Services, LLC, including those services not covered or reimbursed by your insurance, government benefits program, or any other third-party payer.
1.2 You affirm that the information provided regarding your insurance or payment arrangements is accurate and up-to-date. Any changes to this information must be reported to DreamQuest promptly.
2. Payment Terms
2.1 Payment for services rendered is due within 30 days from the date of the invoice unless otherwise specified in a written agreement.
2.2 DreamQuest accepts payments via check, credit card, debit card, bank transfer, or other methods approved by us. Additional fees may apply for returned checks or failed transactions.
2.3 You agree to pay all co-payments, co-insurance, deductibles, and other out-of-pocket expenses at the time of service unless prior arrangements have been made.
2.4 Invoices not paid within the agreed time frame will be subject to a late fee of 1.5% per month or the highest rate permitted by law.
3. Insurance Billing
3.1 DreamQuest will submit claims to your insurance carrier as a courtesy; however, you remain responsible for all charges until payment is received from the insurance carrier.
3.2 You authorize DreamQuest to release medical records and other necessary information to your insurance provider for billing purposes.
3.3 If your insurance denies a claim or provides partial payment, you are responsible for the remaining balance.
4. Pre-Authorization and Coverage
4.1 It is your responsibility to ensure that services provided by DreamQuest are pre-authorized by your insurance carrier if required.
4.2 DreamQuest is not responsible for determining whether services are covered by your insurance. Coverage details and limitations should be confirmed directly with your insurance provider.
5. Third-Party Payers
5.1 If a third party (such as Medicaid, Medicare, or a private insurer) is responsible for payment, you agree to provide all necessary documentation and information for claims processing.
5.2 You acknowledge that any payments received directly from third-party payers for services provided by DreamQuest must be forwarded to DreamQuest promptly.
6. Cancellation and No-Show Policy
6.1 Appointments canceled with less than 24 hours’ notice or no-shows may incur a cancellation fee as outlined in DreamQuest’s Cancellation Policy.
6.2 Repeated cancellations or no-shows may result in suspension or termination of services.
7. Collections
7.1 Accounts more than 90 days past due may be sent to collections. You are responsible for all costs incurred during the collection process, including legal fees, court costs, and agency fees.
7.2 If you encounter financial difficulties, you may contact DreamQuest to discuss alternative payment arrangements, which must be approved in writing.
8. Refunds
8.1 Refunds for pre-paid services not rendered will be issued within 30 days upon approval.
8.2 Refunds will not be issued for services already rendered or for administrative fees.
9. Termination of Services
9.1 DreamQuest reserves the right to suspend or terminate services for non-payment.
9.2 You will remain responsible for any outstanding balances incurred prior to the termination of services.
10. Acknowledgment and Agreement
By signing below, you acknowledge that you have read and understood this Financial Responsibility Agreement. You agree to abide by its terms and accept financial responsibility for all services provided by DreamQuest Home Healthcare Services, LLC.
