Patient Financial Agreement

Odyssey Travel Health, PLLC
Patient Financial Agreement

 

Patient Name: (“Patient” or “you” or “your”).

Thank you for choosing Odyssey Travel Health, PLLC (the “Practice” or “we”). Please take the time to review the information in this Patient Financial Agreement (the “Agreement”) regarding your financial responsibility to the Practice. This Patient Financial Agreement constitutes a binding contract between you and Practice. This Agreement replaces and supersedes any prior agreement between you and Practice on the same or similar subject matter.

Out-of-Network Status of Practice

The Practice does not contract with any private or public insurance companies. Therefore, you must pay for all services rendered by Practice at the end of your visit according to Practice’s rates and terms. Upon request, we will provide you with a statement that you can submit on your own to your private or public insurer for reimbursement.  If you are planning to seek reimbursement, we encourage you to contact your insurance carrier to anticipate your out-of-pocket expenses prior to scheduling an appointment.

Medicaid

The Practice and its providers are not Medicaid providers.  By your signature below, you acknowledge and agree that: (1) the Practice is not contracted with Medicaid, and (2) the services that the Practice provides to you will not be paid by Medicaid.

Medicare

The Practice and its providers are not Medicare providers.  Therefore, the services that the Practice provides to you will not be paid by Medicare. 

Payment

The fee for an appointment is $100 for the first person and $69 for each additional person. The appointment lasts approximately 15-20 minutes. Payment is due upon booking an appointment. Practice accepts credit cards, debit cards and HSA cards. The Practice may revise its rates in the future and will post the revised rates on its website at: https://odysseytravelhealth.com. 

Additional Fees

  • If you need the Practice to assist you with the completion of paperwork related to your treatment, you must schedule an appointment and have it completed in session. If it becomes necessary to complete paperwork outside of the session, anytime over 30 minutes will be charged at a rate of $100 per hour.

  • If a provider of the Practice is subpoenaed or otherwise required to attend a court hearing or other proceeding related to your treatment, you will be billed $100 an hour for the time spent by the provider to attend such hearing or proceeding, including any waiting and travel time. 

  • Practice reserves the right to charge you a fee in accordance with applicable law for providing you or another third party a copy of your chart notes and/or medical records.

Cancellations and Missed Appointments

Your appointment is reserved exclusively for you. Full fees are charged for missed appointments and cancellations. You may request a full refund for appointments canceled at least 7 days in advance of the scheduled date.  

Signature

By your signature below, you agree to the terms of this Agreement and understand your responsibilities herein.

Signature: _________________________ Date:

Name of Patient (Please Print):

 

Date Last Revised: December 15, 2022