• Financial Agreement

    Our goal is to provide you with quality, personal medical care and still maintain a viable business enterprise. This financial policy is intended to help us reach our goal as well as help you derive the most financial benefit from your health insurance plan. Please be advised, you are responsible for all charges incurred.

    1. Payment for any medical service, which is not covered under a contracted insurance plan, is due at the time of service. This includes payment of your co-pay, deductible or coinsurance and any uncovered lab tests. We accept check, cash, Visa, Master Card and Discover. If you are unable to make a payment at the time of service, please contact our business office prior to the visit to make payment arrangements.

    2. For us to help you receive the greatest benefit from your insurance plan, we must have complete insurance information, including the insured’s name, Social Security number, group number, policy number, and the plan’s billing address. This information is provided on your insurance card. We ask that you bring your card with you to every visit. If you are unable to supply us with all information, we will consider you a self-pay patient, and you will be asked to pay in full at the time of service. Furthermore, if we do not have proper insurance information, or if a procedure is scheduled at a facility that does not participate with your insurance plan, you will be held responsible for charges incurred. If your insurance plan does not cover the services provided, you will be held responsible for that portion of the bill.

    3. If you have a change in insurance coverage, please notify us immediately, as we are bound by insurance companies’ strict timely filing requirements. If you do not inform us of an insurance change, and as a result your claims are denied due to timely filing limits, you will be responsible for the charges.

    4. If you have an insurance plan with which we do not contract, you are expected to pay in full at the time of service. We will not submit the claim to the insurance carrier.

    5. As a patient of Colorado Clinic, you understand that if the proper referral from your primary care physician (PCP) and/or proper authorization for the office visits, procedures, etc., is not in place at the time of your visit you could be responsible for any charges incurred for services rendered.

    6. Balances older than 30 days will incur a $5.00 re-billing fee. Balances more than 90 days past due will be considered for collections processing. Any legal and/or collection fees incurred will be your responsibility. An 8% interest charge may be added to accounts over 90 days.

    7. We require 48 hours notice for the cancellation of appointments. If you fail to give proper notice, you will be charged $125.00 for late cancellation of an office visit, or $150.00 for the late cancellation of a procedure.

    8. Any returned checks will be assessed a $20.00 fee. The amount of the check and the fee are to be paid within two weeks. If two checks are returned, we will no longer accept checks as payment from you. You will be required to pay the account by cash, and in person.

    I have read and agree to this Financial Agreement. I understand that failure to comply will be cause for discharge from the practice.

  • I have received, reviewed, and will comply with the patient care policies stated in the following documents: (click to download each)

    1. Patient Financial Agreement

    2. Clinical Policies & Privacy Practices

    3. Informed Consent for Opioid Treatment

  • Received and acknowledged by: