This is an agreement between One Community Health, as creditor, and the Patient/Debtor named.
In this agreement, the words “you,” “your,” and “yours” mean the Patient/Debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words “we,” “us,” and “our” refer to One Community Health.
Financial Agreement
Monthly Statement: If you have a balance on your account, we will send you a monthly statement. It will show separately the previous balance, any new charges to the account, and any payments or credits applied to your account during the month.
Payments: Unless other arrangements are approved by OCH in writing, payment in full will be due within 45 days after insurance resolution and becomes the patient’s responsibility.
Sliding Scale Discounts: OCH offers sliding scale discounts to low-income families who earn up to 200% of the Federal Poverty Guidelines. Sliding scale discounts are based on family size and income. As a federal grantee, we are obligated to request proof of income annually to determine eligibility for sliding scale discounts.
3.1. OCH WILL EDUCATE PATIENTS ON APPLYING FOR THE SLIDING SCALE DISCOUNT AND POSSIBLE ENROLLMENT IN MEDICAID PRIOR TO AN APPOINTMENT. Sliding Fee Payments are due at the time of service.
3.2. OCH has formal written contracts & referral arrangements for certain additional services that the health center does not provide i.e., labs, certain diagnostic imaging, etc. These arrangements have an equal or better slide than OCH in most cases. In cases where the slide is not better, the patient is not responsible for any amount greater than our sliding scale fee. If you have questions regarding our referral partners, please talk with a referral coordinator.
Suspension: OCH shall have the right to suspend scheduling privileges for unwillingness to pay.
Payment options if you have no insurance:
5.1. If you have not completed a Sliding Fee discount application and do not have insurance, you will be expected to pay charges in full. Payment can be made by cash, check, or credit card.
5.2. A minimum prepayment is required on certain medical and dental procedures including, but not limited to circumcision, root canals, and immigration physicals.
5.3. Under some circumstances we will allow you to make special payment arrangements. We will ask you to sign a written payment plan agreement and make payments over a maximum 6-month period. If circumstances prevent your ability to do this, please reach out to a member of our billing staff that will work with you and your situation.
Payment options if you have insurance: You are responsible for co-pays, deductibles, and outstanding balances remaining after your insurance company has paid.
6.1. It is your responsibility to provide all necessary insurance eligibility, identification, authorization, and referral information and to notify our office of any information changes when they occur. Even a preauthorization of services does not guarantee payment from your insurance carrier. It is the patient’s responsibility to know if our office is participating or non-participating with their insurance plan. Failure to provide all required information may necessitate patient payment for all charges. When insurance is involved, we are contractually obligated to collect co-payments, coinsurance, and deductibles, as outlined by your insurance carrier.
Please be aware that out-of-network insurance carriers often prohibit assignment of benefits and may try to limit their financial liability with arbitrary limits, exclusions, or reductions such as reasonable and customary or usual and prevailing reductions. If we are not contracted with your carrier, we will not negotiate reduced fees with your carrier.
6.2. We will bill your insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that
makes the final determination of your eligibility and plan limitations.
6.3. Any balance outstanding will be due within 45 days of insurance resolution.
Returned checks: There is a fee (currently $25) for any checks returned by the bank.
Past due accounts: If your account becomes past due, we will take the necessary steps to collect this debt. If we must refer your account to a collection agency, you agree to pay all the collection costs which are incurred. If we must refer collection of the balance to a lawyer, you agree to pay all lawyers’ fees which we incur plus all court costs. In case of suit, you agree the venue shall be in Hood River County, Oregon.
Waiver of confidentiality: You understand if this account is submitted to an attorney or collection agency, if we must litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.
Divorce: In case of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment for a child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent.
Personal Injury: If you are being treated as part of a personal injury lawsuit or claim, we require verification from your attorney prior to your initial visit. In addition to this verification, we require that you allow us to bill your health insurance. In the absence of insurance, other financial arrangements may be discussed. Payment of the bill remains the patient’s responsibility. We cannot bill your attorney for charges incurred due to a personal injury case.
Effective Date: Once you have signed this agreement, you agree to all the terms and conditions contained herein and the agreement will be in full force and effect.