Financial Responsibility Policy

Dear Valued Customer,

Thank you for choosing Urgent Care at Home hereafter referred to as “Provider”.  We ask that you read and sign this form to acknowledge and agree to accept financial responsibility for services rendered by Provider to Client. A copy of this form will be sent electronically through the patient portal for signature.

I agree that I am legally responsible and agree to pay to the Provider for all fees, charges and expenses incurred by the below signed Client or owed to the aforementioned practice in connection to Provider providing care to Client.

I acknowledge and agree that I am ultimately responsible for the payment to Provider for any and all services rendered by Provider to Client. I understand that if I have a private insurance policy, it cannot be liable for these costs.  If payment is not received within thirty (30) days of the date of service a 20% penalty will be assessed.  If payment is not received within ninety (90) days of the date of service the Provider reserves the right to turn the Client over to a collection agency.

Regarding recurring charges, all requests to cancel any recurring charges must be made in writing 30 days prior to the cancellation. Requests should be sent to meghan.macy@urgentcareathomekc.com

We appreciate your understanding.