At EMG Lab, we believe that all patients who are rendered care at this office deserve the best medical

care that can be provided. For us to provide you with the highest quality medical care and current

technology, we must ensure that we are able to meet the expenses necessary to operate this facility. To

ensure that these expenses are met, we provide you with this Agreement regarding our financial policy

and your agreement to pay for services provided. Please sign and date this Agreement on the last page to

indicate you accept these terms.

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PAYMENT AT TIME OF SERVICE, FEES AND COLLECTIONS

Your insurance policy is a contract between you and your insurance company. We will not become

involved in disputes between you and your carrier regarding deductibles, copayments, non-covered

charges, or “usual and customary” charges. We do provide your carrier with diagnosis and treatment

information. If your carrier does not pay or denies the claim after adjudication, you will be responsible for

the remaining balance. You are responsible for timely payment on your account. We require that you pay

any amount not covered by your insurance, such as deductibles and copayments, on the day of service.

EMG Lab is required by its contract with your insurer to collect deductibles and copayments. We will

determine your copay and how much of your yearly deductible has been met. If you are unable to pay

your copayment at check-in, another appointment will be made for you. Any additional payment owed

will be collected in full at the time of service. If needed, we will work with you to arrange a payment plan.

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We will request your current insurance card and photo identification at every visit so we may bill the

insurance company in a timely fashion. It is your responsibility to provide current, valid insurance

coverage at each visit. If a claim is rejected because your insurance does not cover the service, you will

be responsible for the outstanding balance. Please call your insurance carrier before your appointment to

confirm coverage, whether a referral or prior authorization is required, and your copay and deductible

amounts. It is your responsibility to understand your insurance coverage. If your insurance does not cover

the cost of your visit or procedure, you will be responsible for all charges.

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Once we determine your personal financial obligation or after your insurance company reimburses EMG

Lab, for a portion of your care, we will send a statement, followed by a reminder notice and a final notice.

Payment is expected upon receipt of each statement. Any account that remains unpaid after the final notice

may be referred to our collection agency. If your account becomes delinquent and is placed into our

collection process, collection fees will be your responsibility and added to your balance. EMG Lab

reserves the right to discharge a patient for non-payment upon at least 30 days’ written notice, during

which the practice will provide care for urgent needs and assist the patient in transitioning to another

provider. By signing our financial policy, you agree to pay these added fees, along with all costs associated

with the collection of your account, including interest charges at a rate of 10% per annum and a late fee

of $30 or 10% of the outstanding balance per month, whichever is greater.

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Consistent with Tennessee law, EMG Lab will not furnish information regarding medical debt to any

consumer credit reporting agency.

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If you carry a balance on your account when you present at our office, payment will be required unless a

credit card is kept on file or a payment plan is in place. Under unusual circumstances, we are willing to

work out personalized payment schedules if you can demonstrate need. We accept cash, check, or credit

card.

 

COPAYS AND DEDUCTIBLES

Copays and deductibles may be required by your insurance and plan. This is a contract between you and

your insurance. We also have contracts with your insurance, and we are required to collect these at each

visit. We will not waive any copay or deductible, so please do not ask us to. Failure to pay toward these

at the time of service will result in your appointment being rescheduled.

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REQUIRED PATIENT HEALTH INSURANCE POLICY OR SUMMARY PLAN DESCRIPTION

Insurance companies must provide you with a copy of your health insurance policy and a Summary Plan

Description (SPD) at the time of your policy being effective and/or at annual renewal time. This is required

by federal law. Your insurance policy is an agreement between you, your employer (if your employer

sponsors your health insurance) and the insurance company. Your employer is required to ensure the

insurance company follows the policy requirements properly as they are the fiduciary of your policy (if

your employer sponsors your plan). They cannot require prior authorizations or delay services or payment

on your services whenever they want. They have to follow the rules. If we have your policy or SPD on

hand, we can assist you in assuring your insurance company allows you to obtain services communicated

in your policy.

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BILLING SERVICES / PROCESS

You will receive a letter in the mail from your insurance carrier that explains how much of your office

visit they pay and how much you pay. This is called an Explanation of Benefits, or EOB. This letter tells

you exactly, according to your health insurance coverage, how much of your health care bill is your

responsibility and how much is the responsibility of your insurance to pay. We receive the same letter that

you do. It typically arrives about 20 – 30 days after your appointment. We look at each Explanation of

Benefits (EOB) carefully and determine what your insurance has determined as patient responsibility.

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To better expedite this process, after reviewing your Explanation of Benefits (EOB), a statement is created

and sent out via text message, email, mail, or other electronic means. For your protection, these statements

only show minimal information. For a more in-depth or itemized statement or for any billing questions,

please contact EMG Lab directly.

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After receiving your statement, payment can be made via the link included, by calling EMG Lab, or by

mailing a check to the address below:

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EMG Lab PLLC

PO Box 26

Piney Flats, TN 37686

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We will always work with you to understand if there has been a mistake, and we will refund you if we

have made a billing error. Please do not hesitate to contact EMG Lab with any questions or concerns.

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ELECTIVE PROCEDURES/NON-COVERED PROCEDURES/NO SURPRISES ACT

Patients are required to pay the estimated self-pay portion of elective/non-covered procedures prior to

services being rendered based on insurance verification and eligibility of benefits.

 

In keeping with Federal Regulations regarding items not covered by your insurer (The No Surprises Act),

we will endeavor to provide you with a good faith estimate of what the charges will be for a certain service,

which are due and payable prior to the service being rendered. If the service, when provided, turns out to

be a higher cost than what was estimated, we will provide you with an explanation for the additional costs.

Sometimes, additional services are needed during procedures that we are not aware of at the time of

developing the estimate because of a change in diagnosis, etc. That additional cost will be due and payable

upon receipt of notification from our office.

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SUBMISSION OF CLAIMS

We will submit your insurance claims as a courtesy. However, your insurance is a contract between you

and your insurer, and you remain responsible for payment regardless of the amount your insurance pays.

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PAYMENT OPTIONS

Our office accepts most credit and debit cards. Our office also accepts valid check or cash. There will be

a $30 fee or the maximum amount permitted by Tennessee law for all returned checks, whichever is less.

Once we have a returned check for you, we may require that all future payments be with cash, money

order, cashier’s check, or credit card. Anytime a copay, deductible, or balance is due, we will charge the

fee to your credit card, which will help to keep you at a zero balance and paid up in full with your credit

card on file. Any charges to a credit card will incur the additional credit card fee charged to EMG Lab.

We will charge a surcharge of up to 3% on credit card payments to offset the credit card processing fees

borne by EMG Lab, not to exceed our actual cost of acceptance. This surcharge does not apply to debit

card payments.

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Credit Card on File Authorization. By signing below, I authorize EMG Lab to keep my credit card

information on file and to charge the card for the following: copays, deductibles, and patient-responsibility

balances after insurance adjudication, up to a maximum of $[___] per charge. I will receive advance notice

before any charge is processed, or any charge will not exceed the stated maximum. Card data will be

stored in a PCI-DSS-compliant and HIPAA-compliant manner. This authorization may be revoked at any

time by written notice to EMG Lab, and revocation will take effect upon receipt.

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CASH PAYMENT

If you wish to pay cash, you will always be provided with a receipt so that you will have a record of your

payment. Please make us aware if you are not provided a receipt.

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MEDICAL DEBT

A holder of any medical debt contract is prohibited by T.C.A. § 24-5-113 from furnishing any information

related to this debt to a consumer credit reporting agency. In addition to any other penalties allowed by

law, if a person knowingly violates that section by furnishing information regarding this debt to a

consumer credit reporting agency, the debt shall be void and unenforceable.

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MEDICARE PATIENTS

If you have Medicare as your primary insurance carrier, but you do not have a secondary insurance, you

are responsible for the deductible, copay, and co-insurance at the time of service. You are also responsible

to pay for services not covered by your Medicare insurance unless you have a secondary insurance. You

will be required to sign an Advanced Beneficiary Notice for services we believe may not be covered by

Medicare.

 

NON-CONTRACTED INSURANCE (Out of Network)

If you have an insurance plan that we do not participate with, you may or may not have out-of-network

benefits. These benefits typically have a higher copay, coinsurance, and/or deductible out-of-pocket cost.

You will be considered a self-pay, uninsured patient if you do NOT have out-of-network benefits, and if

your insurance does not pay for the service, you are financially responsible. Please understand that what

your non-contracted insurance deems “allowable” may not cover the entire charge, and you would be

responsible for any difference.

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UNINSURED/SELF-PAY

We offer a discount to all self-pay patients who pay in full at time of service. Payment is expected at each

visit. We require payment in advance of half of the services scheduled with us to schedule your first visit

with us which will then be used toward the total cost of your first visit or applied to as payment towards

your co-pay and the balance left will be credited or returned to you, whichever you prefer. If you fail to

show up for your visit, this will be determined as payment for not showing up for your appointment.

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As an uninsured or self-pay patient, you are entitled to receive a Good Faith Estimate of expected charges

before scheduled services, in accordance with the No Surprises Act and its implementing regulations.

Please see the Elective Procedures/Non-Covered Procedures/No Surprises Act section of this policy for

additional information.

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MISSED APPOINTMENTS/NO SHOWS/LATE FOR APPOINTMENT

We understand you may not be able to keep all scheduled appointments or might occasionally be late.

Missed appointments affect our ability to serve other patients in need of care. If you must cancel or

reschedule, please do so at least 24 hours in advance. Failure to do so will be considered a no-show. We

reserve the right to charge $50 for any no-show if permitted by law and your insurance contract. This fee

is not charged to Medicaid beneficiaries and is applied uniformly to all patients to the extent required by

applicable payer rules. Payment of the missed-appointment fee will be required prior to scheduling another

appointment. EMG Lab reserves the right to terminate any patient with more than two no-show

appointments upon 30 days’ written notice.

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If you are running late on the day of your appointment due to unforeseen circumstances, please contact

our office immediately so that we can determine whether we can see you that day or if we will need to

reschedule your appointment. If you are more than 15 minutes late for an appointment, EMG Lab may

reschedule your appointment and refuse to see you at the originally scheduled time.

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REFERRALS

If your insurance carrier requires a referral or authorization for your visit, it is your responsibility to make

sure that our office receives current valid authorization. If you do not have a valid referral or authorization

at the time of service, we will be unable to treat you until a valid authorization/referral is obtained, and

you may be sent back to your primary care physician to obtain authorization prior to being treated or full

payment will be expected at the time of service. Please remember that it is your responsibility to make

sure we are on your plan’s provider listing. We appreciate your understanding of the ever-changing

requirements of managed care plans and our position to adhere to their policies or requirements.

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AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize EMG Lab: to (1) release any information necessary to insurance carriers regarding my

illness and treatments; (2) process insurance claims generated in the course of examination or treatment;

and (3) allow a photocopy of my signature to be used to process insurance claims for all services provided

to me by EMG Lab. This order will remain in effect until revoked by me in writing.

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ASSIGNMENT OF BENEFITS, ASSIGNMENT OF RIGHTS TO PURSUE ERISA AND

OTHER LEGAL AND ADMINISTRATIVE CLAIMS ASSOCIATED WITH MY HEALTH

INSURANCE AND /OR HEALTH BENEFIT PLAN (INCLUDING BREACH OF FIDUCIARY

DUTY) AND DESIGNATION OF AUTHORIZED REPRESENTATIVE

I, hereby, as the beneficiary/participant of a health care plan governed by the Employee Retirement

Income Security Act (hereinafter, ERISA) and the Patient Protection and Affordable Care Act (hereinafter,

PPACA), do hereby appoint and specifically designate EMG Lab to act as my AUTHORIZED

REPRESENTATIVE pursuant to C.F.R. § 2560.503–1(b)(4).

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I hereby authorize and instruct my ERISA plan administrator and/or fiduciary, and/or ERISA insurer, to

release to such AUTHORIZED REPRESENTATIVE any and all plan documents, insurance policy or

policies upon written request from such AUTHORIZED REPRESENTATIVE in order to claim such

medical benefits, reimbursement or any applicable remedies.

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I hereby convey to the above named AUTHORIZED REPRESENTATIVE, to the full extent permissible

under the law, including but not limited to, any ERISA claim for benefits, breach of ERISA fiduciary

duty, and ERISA claim for statutory penalties for failure to produce documents or information in

accordance with ERISA §502(a)(1)(B), §502(a)(3) and §502(c)(1)(B), under any applicable employee

group health plan(s), insurance policies or public policies, any benefit claim, liability or tort claim, chose

in action, appropriate equitable relief, surcharge remedy or other right I may have to such group health

plans, health insurance issuers or tortfeasor insurer(s), with respect to any and all medical expenses legally

incurred as a result of the medical services I received or was prescribed, and to the full extent permissible

under the law to claim or lien such medical benefits, settlement, insurance reimbursement and any

applicable remedies including, but not limited to, (1) obtaining information about the claim to the same

extent as the beneficiary; (2) submitting evidence; (3) making statements about facts or law; (4) making

any request, or giving, or receiving any notice about appeal proceedings; and (5) any administrative and

judicial actions by such AUTHORIZED REPRESENTATIVE to pursue such claim, chose in action or

right against any liable party, party-in-interest, or employee group health plan(s), including, if necessary,

funding and authority to bring suit by such AUTHORIZED REPRESENTATIVE against any such liable

party, party-in-interest, or ERISA employee group health plan, in my name.

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I understand that I am financially responsible for all charges regardless of any applicable insurance or

benefit payments. I hereby authorize the above-named health care provider to release all medical

information necessary to process my claims. Further, I hereby authorize my plan administrator fiduciary,

insurer, and/or attorney to release to the above-named health care provider any and all Plan documents,

summary benefit description, insurance policy, and/or settlement information upon written request from

the above-named health care provider or its attorneys in order to claim such medical benefits.

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In addition to the assignment of the medical benefits and/or insurance reimbursement above, I also assign

and/or convey to the above named health care provider any legal or administrative claim or chose in action

arising under any group health plan, employee benefits plan, health insurance or tort feasor insurance

concerning medical expenses incurred as a result of the medical services, treatments, therapies, and/ormedications I receive from the above-named health care provider (including any right to pursue those

legal or administrative claims or chose in action). This constitutes an express and knowing assignment of

ERISA breach or fiduciary duty claims and other legal and/or administrative claims.

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Unless revoked, this APPOINTMENT OF ERISA and PPACA AUTHORIZED REPRESENTATIVE is

valid for all administrative and judicial reviews under ERISA and PPACA, and/or any applicable federal

or state laws. A photocopy of this Appointment of ERISA Authorized Representative is to be considered

as valid as the original.

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To the extent any plan’s terms or applicable law bar the assignment of any claim (including breach-of-

fiduciary-duty or statutory-penalty claims), this instrument shall instead operate as a designation of EMG

Lab as my authorized representative to the fullest extent permitted.