Agreement to Pay
- The information I am giving you is correct.
- Telemedicine Group DE, L.L.C. dba TeleMed2U (“TeleMed2U”) and Cloud Health Medical Group, P.A., Cloud Health Medical Group of California, P.C., Cloud Health Medical Group of New Jersey, P.A., and Cloud Health Medical Group of Kansas, P.C. (collectively, “Cloud Health Medical”), and my doctor may release or share any information needed to process my claims, including with a division of state or local government authorized to reimburse my claims.
- TeleMed2U, Cloud Health Medical, and those providing my care shall be paid or assigned benefits on my behalf.
- I will cooperate with and provide documentation to my insurance company or other third-party payer as needed to process my claims.
- I am responsible for any costs not covered by my benefits, including non-covered services, deductibles, and co-insurance.
Assignment of Benefits
I request and agree that any benefits due me for my treatment by all insurance companies or other third-party payers responsible for my care shall be paid or assigned to TeleMed2U or Cloud Health Medical. This includes any insurance company settlements related to my treatment. If my insurance company or other payer will not pay TeleMed2U or Cloud Health Medical directly for my care and treatment at TeleMed2U and Cloud Health Medical, I will immediately forward payments I receive to TeleMed2U and Cloud Health Medical.
Noncovered Services
I understand that my insurance or payer may not cover all my costs. I agree that I am personally responsible for:
- Any costs not covered by my insurance or payer or that exceed my benefit limits, including, but not limited to:
- self-administered medications (medicines I would normally take on my own).
- Certain durable medical equipment.
- Certain medical supplies.
- Services and supplies that my insurance or payer determines are experimental or investigational, are not covered for another reason, or are not medically necessary but that I want to receive.
CMS-Governed Plans
If I am a beneficiary of a government health program, I agree that neither I, my healthcare provider, the affiliated physician practices, nor any healthcare organization or provider with whom TeleMed2U or Cloud Health Medical partners to provide healthcare and pharmacy services to me will submit a claim for reimbursement to any federal or state healthcare program, except Medicare Advantage plans, for the costs of services and products provided through the Services. Submission of claims to Medicare Advantage plans is expressly permitted. All other government program claims, including Medicare Part B fee-for-service, Medicaid, TRICARE, and Veterans Affairs, are strictly prohibited.
Guarantor Agreement
I understand and agree that:
- I—or the person signing or guaranteeing payment for me (“Guarantor”)—am responsible for any charges not covered by my insurance, for any reason. Such charges are due when my treatment stops or I am discharged.
- I may request an estimate of charges based on the TeleMed2U or Cloud Health Medical price list (“chargemaster”) in effect at the time of service. The estimate may need to be prepared and mailed to me. It is only an estimate, and actual costs may vary.
- TeleMed2U or Cloud Health Medical may bill my insurance for me. TeleMed2U and Cloud Health Medical may also require me to pay in full in advance unless they have agreed with my insurance company or other payer not to do so.
- I may be billed by TeleMed2U or Cloud Health Medical.
- I am responsible for all charges, and this agreement covers all TeleMed2U and Cloud Health Medical accounts, including accounts for doctors, nurse practitioners, and physician assistants. If my bill is sent for collection, I will pay resulting costs, including attorney’s fees, court costs, and collection-agency fees.
- TeleMed2U, Cloud Health Medical, and their providers, affiliates, agents, and contractors, including debt collectors, may call or text my cell or home phone using any type of artificial or prerecorded voice or auto-dialer technology for any purpose, including billing and collections.
- TeleMed2U or Cloud Health Medical may access my consumer credit report to help collect what I owe or determine whether I am eligible for financial aid or charity care.
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