ジャパニーズメディカルケア及び所属の医師・専門家をご利用頂きまして誠にありがとうございます。米国の複雑な保険会社の契約・給付内容や、患者様（保険契約者）様としての支払責任等をご理解していただく為、弊院の支払いに関する方針を以下記載致します。患者様の保険契約は、患者様と保険会社或いは患者様の雇用主の間の契約になります。患者様には保険契約者として保険会社との間の特別な規定・契約内容（指示書、事前保障、事前承認等の必要性、外来患者治療費の限度額、その他必要な治療範囲・検査・病院への紹介を含む）を認識、ご理解頂く必要がございます。また、患者様はdeductible (保険免責額)、co-payment（自己負担額）、coinsurance（自己負担割合） を知る必要があります(下記に詳細明記)。患者様の保険契約・給付内容についてご不明な点がございましたら、ご契約の保険会社或いは雇用主の保険担当者に詳細をお問い合わせください。
BCBSと United Healthcare Oxford の対応について
1. Release of Information
I hereby authorize and direct Japanese Medical Care, PLLC and/or any provider or organization rendering medical services at the offices located below to release to governmental agencies, insurance carriers, or others who are, or may be, financially responsible for my medical care, all information needed to substantiate payment for such medical care, and to permit representatives thereof to examine and make copies of all records relating to my care and treatment.
2. Assignment of Benefits
I hereby assign to Japanese Medical Care, PLLC and/or any provider or organization rendering medical services at the offices located below any and all benefits, including benefit of payment, to which I may be entitled from any governmental agency, insurance carrier, or others who are financially responsible for the medical care rendered to me or my dependent at said offices.
3. Blue Cross and Blue Shield, United Healthcare and Oxford Subscribers
I have been advised that my provider(s) is/are not participating with the above insurances and therefore I will be fully responsible for the cost of services. A courtesy claim will be sent to my insurance carrier on my behalf. If my insurance carrier sends payment to me for the service, I will immediately remit the payment and explanation of benefits to Japanese Medical Care, PLLC.
4. Financial Agreement and Guarantee
For services rendered or to be rendered, the undersigned agrees to pay to Japanese Medical Care, PLLC and/or any provider or organization rendering medical services the full amount of bills not paid by my insurance plan. I understand that all such bills are due and payable at the time services are provided or upon receipt of a statement from our billing office. Payment may be demanded at any time from either of the undersigned and failure to demand payment of the patient shall not be a prerequisite to the guarantor’s immediate responsibility for payment.
I have read this agreement and fully understand it’s nature and significance. I have retained a copy of this agreement and a copy of Japanese Medical Care, PLLC’s Payment Policy.
Japanese Medical Care, PLLC has implemented a new credit card policy. Much like many other businesses such as a hotel or car rental agency, attorneys, etc. we now have a similar policy where we ask for a credit card which may be used later to pay any balance that may be due on your bill.
At check in, your credit card information will be obtained and kept securely until your insurance(s) have paid their portion and notifies us of the balance due, if any.
Your ability to dispute a charge or question your insurance company’s determination of payment will remain unchanged.
If you have any questions about our policy, please do not hesitate to ask.