Benefits: No Copays, Co-Insurance or Deductibles will be due until 2 weeks after the shutdown has been lifted.
In order to be eligible for Participation:
Participant must sign a letter stating that they are requesting a hardship due to the fact the individual or their family has been directly affected by the shutdown
ACH form must be signed with Primary Checking account number agreeing to pay the full amount of the Patient Responsibility as determined by their insurance payer or the CMG/First Call Self Pay Fee Schedule, to be drafted 2 weeks after the shutdown has been lifted.
Provide Company and phone number for us to call and verify their status of the employee and current furloughed situation.
If the employer cannot be reached, Patient must present proof of furloughed status. If proof is not received within 30 days, payment will be withdrawn 30 days from time of service.
Insurance Card must be presented at time of service or will be subjected to self-pay rates.
Patient agrees if their status changes and they return to work, before the shutdown is lifted, and their regular paycheck resumes, to contact the office to authorize withdraw within 14 days of returning to work.
Any violations of these rules and regulations will be subject to a disqualification from the program, and no discounts will be made to the CMG/First Call Fee schedule, and immediate withdraw will occur for Patient Responsibility.
Any accounts not paid within 2 weeks, will be given a 16 day grace period for payment, and then will be subject to collection and the collection fee of 33% on top of their regular balance.