Terms of Services

TRANSACTION FEES

Effective 02/15/2023, our vendors will be adding a fee for all credit card transactions.

TEXT AND EMAIL COMMUNICATION NOTICE

You hereby expressly consent to the practice sending you any type of electronic message (including, without limitation, other commercial communications, informational communications, and electronic notices, and updates), whether through the site or by telephone, e-mail, online social media, or any other electronic media means or forms. By giving such consent, you agree that no such communication shall violate the telephone consumer protection act, the CAN-SPAM Act or any other applicable laws, rules, or regulations. Voice, message, and data fees, rates, charges, and/or taxes may apply to you, and you are responsible for payment of the same. You are not required to grant the foregoing consent as a condition for the use of the site and can opt out of electronic communications at any time.

EMERGENCY CONTACT AGREEMENT

Patients will provide the Practice with contact information for the Patient's guardian(s) or next of kin, which information will be used to contact the Patient's /guardian(s) or next of kin (as the case may be) in case of emergency or in cases where it is deemed necessary for the safety, security and/or wellbeing of the Patient or other community members, or where the Patient is otherwise incapacitated. Regardless of the Patient's age, the Patient will not make any objection to or seek to hold the Practice liable whatsoever for such contacting of the Patient's guardian(s) or next of kin (as the case may be). This Agreement covers any previous emergency contacts or any future contacts that are to be provided and is applicable regardless of whether the Patient notifies us of the contact verbally or in writing.

FINANCIAL POLICY

APPOINTMENTS

  1. Copayments. Copayments for clinic visits are due at the time of service. If you are unable to make your copayment at the time of service, Sussex Pain Relief Center reserves the right to reschedule your appointment until a time that you can make your copayment. Payment for any outstanding balance is due at the time of your appointment.
  2. Missed Appointments and Late Arrivals. If you are more than 15 minutes late, we may reschedule your appointment. If you are more than 60 minutes late, or if you do not show up to your appointment, you will be responsible for a missed appointment fee. Missed office visit appointments are subject to a $35 charge. Missed procedures are subject to a $100 charge. These charges are your responsibility and will not be billed to any insurance carrier.

INSURANCE PAYMENTS

  1. Financial Responsibility. Your insurance policy is a contract between you and your insurance carrier. You are ultimately responsible for payment-in-full for all medical services provided to you. Any charges not paid by your insurer will be your responsibility, except as limited by our contract (if any) with your insurance carrier.
  2. Coverage Changes and Timely Submission. It is your responsibility to inform us in a timely manner of any changes to your billing or insurance information. There is a time limit within which Sussex Pain Relief Center must submit a claim on your behalf to your insurer. If Sussex Pain Relief Center is unable to submit your claim within this period because we have not been supplied with your correct insurance information, you will be responsible for the charges.
  3. Self-Pay. If you do not have health insurance, or if your health insurance will not pay for services rendered by Sussex Pain Relief Center, you will be considered a self-pay patient. Your charges will be based on our current self-pay schedule. Self-pay patients are expected to make payment in full at the time of service or at the time they are billed.

BENEFITS AND AUTHORIZATION

  1. Insurance Plan Participation. We participate in many but not all insurance plans. It is your responsibility to contact your insurance company to verify that your assigned physician participates in your plan. Out-of-network charges may have higher deductibles and copayments.
  2. Referrals. Referral and prior authorization requirements vary widely among insurance carriers and plans. If your insurance carrier requires a referral for you to be seen by Sussex Pain Relief Center, it is your responsibility to be aware of this fact and to obtain this referral.
  3. Prior Authorization and Non-Covered Services. Sussex Pain Relief Center may provide services that insurance plans exclude or require prior authorization to pay for. If insured, it is ultimately your responsibility to ensure that services provided to you are covered benefits authorized by your insurer. Sussex Pain Relief Center, as a courtesy to our patients, makes a good faith effort to determine if services we order are covered by your insurance plan, and, if so, whether prior authorization for treatment is required. If we determine that a prior authorization is required, we will attempt to obtain such authorization on your behalf.
  4. Out-of-Network Payments. If we are not part of your insurance carrier's network (out-of-network) and your insurance carrier pays you directly, you are solely responsible for payment and agree to immediately forward the payment to Sussex Pain Relief Center.

ACCOUNT BALANCES AND PAYMENTS

Refill requests will only be honored if it's made during your follow-up visits. No refill requests will be honored if they're made in between follow-up visits. It is highly recommended that patients bring prescription bottles of medication that has been ordered by our office to each follow-up visit in-person. During telehealth visits, patients can line up the medication bottles on a table.

Please be advised that it is the patient's responsibility to notify providers at the time of their visit that they need a refill on their medication.

  1. Reassignment of Balances. If your insurance company does not pay within a reasonable time, we may transfer the balance to the patient, so they are your sole responsibility. Please follow up with your insurance carrier to resolve non-payment issues. Balances are due within 30 days of receiving a statement.
  2. Collection of Unpaid Accounts. If you have an outstanding balance over 120 days old and have failed to make payment arrangements (or become delinquent on an existing payment plan), we may turn your balance over to a collection agency and/or an attorney, which may result in reporting to credit bureaus and/or legal action. Sussex Pain Relief Center reserves the right to refuse treatment to patients with outstanding balances over 120 days old. You agree to pay Sussex Pain Relief Center for any expenses we incur to collect on your account, including reasonable attorneys' fees and collection costs.
  3. Returned Checks. Returned checks will be subject to a $38 returned check fee.
  4. Refunds. Refunds for overpayment are made only after there has been full insurance reimbursement for all medical services on your account. Please submit a written refund request and allow four to six weeks for your request to be processed.
  5. Statements. Charges shown by statement are agreed to be correct and reasonable unless protested in writing within thirty (30) days of the billing dates.

REFILL POLICY

Refill requests will only be honored if it's made during your follow-up visits. No refill requests will be honored if they're made in between follow-up visits. It is highly recommended that patients bring prescription bottles of medication that has been ordered by our office to each follow-up visit in-person. During telehealth visits, patients can line up the medication bottles on a table.

Please be advised that it is the patient's responsibility to notify providers at the time of their visit that they need a refill on their medication.