Financial & Practice Policies / Patient Agreement

Insurance and benefits

• Insurance coverage and benefits are determined by my health plan.
• Verification of insurance eligibility or benefits by Luminox Healthcare Services LLC is not a guarantee of payment by my insurance company.
• I am responsible for providing current and accurate insurance information and notifying the practice promptly of changes.
• I may be financially responsible for applicable deductibles, copayments, coinsurance, non-covered services, denied claims attributable to my coverage or eligibility, and other patient responsibility permitted by my insurance contract and applicable law.

Payment

• Patient-responsibility amounts are due according to Luminox Healthcare Services LLC's payment policies and applicable payer requirements.
• Luminox Healthcare Services LLC may request an authorized method of payment when permitted by law and applicable payer contracts.
• I will be informed of applicable charges before services when required by law.

Self-pay and Good Faith Estimates

Patients who are uninsured or who choose not to use insurance may have rights under federal law to receive a Good Faith Estimate of expected charges.

Receiving a Good Faith Estimate does not require a patient to obtain services from Luminox Healthcare Services LLC.

Federal No Surprises Act requirements provide Good Faith Estimate protections for uninsured and self-pay patients and a dispute process when qualifying billed charges substantially exceed an estimate.

Appointments, cancellations, and no-shows

Appointments reserve clinical time specifically for me.

• I will provide at least 24 hours’ notice before the scheduled appointment time when I need to cancel or reschedule.
• Appointments canceled with less than 24 hours’ notice and missed appointments or no-shows may be subject to a $75 late-cancellation/no-show fee, except when prohibited by applicable law, payer requirements, or contractual obligations, or when the practice determines that an exception is appropriate based on the circumstances.
• The $75 fee is generally the patient’s responsibility and is not billed to insurance as a covered clinical service.
• Repeated missed appointments may affect the practice's ability to maintain scheduled treatment. Any decision regarding continuation or termination of an established treatment relationship will take clinical circumstances, patient safety, continuity of care, applicable law, and professional obligations into consideration.

Late arrival

Late arrival may shorten the available appointment time or require rescheduling when there is insufficient time to provide safe and clinically appropriate care.

Prescription refills

• Routine medication refills should be requested sufficiently in advance of running out of medication.
• Routine refill requests are not emergency services and may not be processed immediately.
• Medication refills are subject to clinical appropriateness, monitoring requirements, follow-up attendance, applicable prescribing laws, and the provider’s professional judgment.
• A prescription or refill is not guaranteed merely because it is requested.

Controlled substances

• Controlled medications may require additional monitoring, follow-up appointments, prescription-monitoring-program review, toxicology testing when clinically appropriate, or a separate Controlled-Substance Treatment Agreement.
• Receiving controlled substances from multiple prescribers without appropriate disclosure and coordination may create serious safety concerns and may affect the provider’s ability to prescribe controlled medications safely.
• Patients are expected to disclose all medications and controlled substances prescribed by other healthcare professionals.

Prior authorizations

Luminox Healthcare Services LLC may assist with insurance prior authorizations when clinically appropriate.

Submission of a prior authorization does not guarantee that an insurance company will approve or pay for a medication or service.

Forms, letters, and administrative requests

Completion of disability forms, employment forms, school documentation, accommodation requests, legal forms, extensive medical-record reviews, letters, or other administrative services may require additional processing time, clinical evaluation, or a fee when legally permitted.

Completion of a requested document is not guaranteed when the provider cannot clinically substantiate the requested information.

Electronic communication

• Patient portal messages, emails, text messages, voicemail, and routine telephone communications are not emergency services and may not be reviewed immediately.
• For an immediate or life-threatening emergency, call 911 or go to the nearest emergency department.
• For mental health, suicide, emotional distress, or substance-use crisis support, call or text 988.

Respectful and safe conduct

Patients, family members, staff, and clinicians are expected to interact respectfully.

Threats, violence, harassment, discriminatory abuse, or behavior creating a significant safety risk may result in appropriate safety measures and may affect continuation of services.

Any termination of an established treatment relationship will be handled according to applicable clinical, ethical, contractual, and legal requirements, including appropriate consideration of continuity of care.

No guarantee of treatment outcome

Healthcare outcomes cannot be guaranteed.

Treatment recommendations and prescribing decisions are based upon the provider’s professional judgment, available clinical information, applicable standards of care, and the patient’s individual circumstances.

Acknowledgment

I acknowledge that I have reviewed and understand Luminox Healthcare Services LLC's Financial & Practice Policies.