PATIENT FINANCIAL POLICY
The following statement is our Financial Policy as it pertains to Patients.
It is required that the patient and/or responsible party read and sign
this statement prior to any treatment. All patients and/or responsible
parties must also complete and sign our “CONSENT TO TREATMENT”
form prior to treatment.
Payment in full is expected at the time of service. Payment arrangements
must be made prior to service with the Business Office.
We accept cash, checks. Discover, Visa, or MasterCard.
Monroe Hospital reserves the right to accept or deny assignment of insurance
benefits; if we accept assignment of benefits it is the patient’s
responsibility to supply our office with a copy of a current insurance
card. Please note that an insurance policy is a contract between you and
your insurance company. The balance remaining after your insurance processes
the account is your responsibility. In the event we do accept assignment
of benefits and your insurance company has not paid your account in full
within 60 days, you will be expected to pay your balance. Please keep
in mind that some, and perhaps all of the services provided may be non-covered
services. Also be aware that some services may not be considered reasonable
and/or necessary under the Medicare Program or other medical insurance.
We currently do not ask for co-pays or deductibles at time of service.
We do ask for co-pays for patients seen in the Emergency Department.
It is your responsibility to supply us with a copy of your current card
at the time of service. In the case of an emergency we must receive this
information within 24 hours of service. The patient is responsible for
the full/entire balance if the information is not received. We accept
Indiana Medicaid only. If you are an out-of-state Medicaid recipient,
you may make arrangements with the Business Office to set up a payment schedule.
Your employer must complete and sign a written authorization/incident
report form. It is your responsibility to bring this completed form with
you along with all billing information for your account (carrier name
and address, contact person, telephone number and claim number if applicable).
This information must be provided to us prior to treatment. If your account
is not paid in full within 60 days, you are responsible and will be expected
to pay your unpaid balance. Monroe Hospital will not accept a delay in
payment due to a worker's compensation dispute and/or litigation.
We may accept assignment of your health insurance benefits.
If you are being seen due to a liability injury, you must provide the
following information for billing and verification of payment prior to
*Auto Accident: If you are injured in your personal vehicle, you must provide us with
the name and address of your auto insurance carrier, claims adjuster’s
name and phone number, claim number and date of accident. If your injury
occurred in someone else's vehicle, we require all of the above information
AND the following:
theirname, the name and address of
their auto insurance company,
their agent/adjuster's name, telephone number and
their claim number. Monroe Hospital will bill the auto insurance company of
the at-fault party involved in the accident as a courtesy only. As the
patient, you are ultimately responsible for payment.
* Slip and fall. Other accidents, Etc: if you were injured on residential property or in a residential dwelling,
we require the following:
Homeowner’s name, the name and address oftheir homeowner's insurance company,theiragent/adjuster's name, telephone number,their claim number and the date of accident. If your injury occurred at a place
of business, please provide the same information.
If your account is not paid in full within 60 days, you are responsible
and will be expected to pay your unpaid balance. Monroe Hospital will
not accept a delay in payment due to settlement disputes and/or litigation.
We may accept assignment of your health insurance benefitsonly after your liability insurance has been paid/denied.
*Veterans Administration Benefits: VA Benefits are not considered insurance. Insurance such as Blue Cross,
Medicare or any commercial insurance must be billed. There may be co-pays
associated that the patient will be responsible for paying.
The parent/guardian accompanying a minor is responsible for payment of
the minor's account balance. A minor who is not accompanied by a parent/guardian
will be denied anynon-emergency treatment unless charges for the treatment have been pre-authorized. Consent
of a parent or guardian is unnecessary if the medical treatment is for
infectious, contagious, or communicable disease.
CONSENT TO FINANCIAL RESPONSIBILITY
Assignment of Benefits and Release of Records
I hereby assign to
Monroe Hospital the medical benefits to which I, or my dependents are entitled. I also
authorize Monroe Hospital to furnish my health insurance carrier all my
patient information including but not limited to any and all medical records,
notes, test results, x-ray reports, MRI reports or other documents related
to my treatment (including itemization of any charges and payments on
my account) that is deemed necessary to process this claim. I also authorize
Monroe Hospital to release any and all patient information and medical
records necessary to collect this debt. I also understand a returned check
fee will be assessed to my account for any check declined by my financial
Collection Costs and Procedures
If my account becomes delinquent, I agree to pay any additional charges
to collect the unpaid bills, including but not limited to reasonable attorney
fees, and court costs and collection agency fees. By signing this policy,
I acknowledge that Monroe Hospital reserves the right to release any patient
information and any medical records to their collection agency deemed
necessary to assist their staff and their attorneys in the collection
of this debt.