Financial Agreement

Thank you for trusting Project Vida Health Center as your healthcare provider. This financial agreement should answer questions regarding patient and insurance responsibility for services rendered. Please read this agreement, ask us any questions you may have, and sign in the space provided. You will be given a copy of this agreement for your records.

I have received this financial policy, and understand that regardless of any insurance coverage I may have, I am responsible for payment of my account.

---

Insurance

Your insurance coverage is a contract between you and the insurance company, and it is your responsibility to know your insurance benefits. As a courtesy, we will bill both your primary and secondary insurance companies. We will submit your claims and assist you in any way we reasonably can to help get your claims processed. In order to do this, we must receive all the information necessary to bill. If the information is not supplied, you will be billed, and payment in full will be your responsibility and will be expected within 30 days of receipt of statement.

Medicaid

Texas Medicaid is accepted and welcomed. If you have private insurance as well as Medicaid we will bill the private insurance as the primary and the remaining will be billed to Medicaid.

Medicare

We participate in Medicare program in which you are responsible for:

• Your co-insurance
• Services that are identified as patient responsibility on your Medicare Explanation of Benefits
• Deductibles will be waived as part of our FQHC program

Patient Responsibility for Payment

You are responsible for payment of:

• Co-payment
• Co-insurance
• Deductible
• Services not covered by your insurance

If you do not have insurance, you are eligible to apply for the “Project Vida Health Center Discount”. Co-payments are due at the time of your service. Patient due balances noted on your monthly statement are due within 30 days of receipt. Charges for minor children will be billed to the parent with whom the child resides. We will bill appropriate insurance if all required information is provided. We will not bill or contact a non-custodial parent on behalf of the custodial parent.

Payment Options

We understand there are financial struggles, if you are unable to pay your patient due balance in full, we recommend you call your clinic and request a promissory note to work out a payment plan. We offer uninsured patients a discount depending on household size and income; Project Vida will not deny services for inability to pay, but documentation will be required.