Patient Financial Responsibility Agreement
I understand that by signing this Patient Financial Responsibility Agreement, I consent to the terms and conditions set forth below regarding the professional therapy services I receive from providers using the UpLift Health Technologies, Inc. and UpLift Behavioral Health PC (“UpLift”) platform.
I acknowledge and agree as follows:
- I assume full responsibility, and agree to pay all costs, charges, co-payments and expenses of every kind and description for all services provided to me by UpLift and my provider using the UpLift platform.
- Each bill for any charges from UpLift or the providers using the UpLift platform will be due upon completion of your session.
- UpLift accepts most major credit cards and payments via ACH.
- If I have a health insurance policy, I have carefully read the section in my health insurance policy that describes mental health services. If I have questions about my coverage, I will call the plan administrator to ask questions and clarify my benefits. I am responsible for knowing what my insurance plan will and will not cover.
- If I have a health insurance policy, I have provided UpLift with the most correct and updated information about my insurance. If I provide UpLift with incorrect information about my insurance, I will be fully responsible for any charges for the cost of my therapy services provided through the UpLift platform.
- I may incur additional charges at the discretion of UpLift, including without limitation charges for credit card payment processing fees, missed appointments without notice per UpLift’s policies, charges for extensive phone consultations and/or after-hours calls, and any costs associated with the collection of my unpaid balances.
- I authorize UpLift and the providers using the UpLift platform to release my medical and other information acquired in the course of my examination and/or treatment to the necessary insurance companies, other third party payors, and/or other physicians or healthcare entities required to participate in my care.
- I authorize assignment of financial benefits directly to UpLift and the providers using the UpLift platform for any services rendered as allowable under standard insurance and other third-party payor contracts. I understand I am financially responsible for charges not covered by this assignment.
I understand that the terms herein are contractual and not a mere recital and that I sign this document as my own free act and void of any coercion.
I understand that clicking “I Agree” constitutes a legal signature and verifies that I have read all of the information contained in this Patient Financial Responsibility Agreement.
