KMG Medical Group Self Pay Agreement

Agreement for Payment of Services

Effective: March 28, 2022 Last Updated: July 12, 2024

KMG Medical Group MO, P.C., KMG Medical Group NJ, P.C., KMG Medical KS, P.A., KMG Medical Group TX, P.A., Michael Karagas, M.D., P.C. d/b/a KMG Medical Group (collectively, the “Medical Group”) is committed to providing the best quality telemedicine services (the “Services”). This Agreement for Payment of Services (“Agreement”) outlines your financial responsibility in relation to receipt of the Services from the Medical Group. By accepting this Agreement, you certify that you have read and understand the following and received a copy thereof and that you are the patient, the patient’s legal representative, or are otherwise duly authorized by the patient to accept this Agreement on their behalf.

PAYMENT OPTIONS

Medical Group accepts certain insurance plans; however, Medical Group does NOT accept any government health insurance plans including Medicare, Medicaid, and Tricare or any of their affiliated managed care plans. Please let Medical Group know if you have eligible medical insurance that you plan to use for payment of the Services. Medical Group also offers a self-pay option for the Services. Please see the Self-Payment for Services section below for information on self-pay options.

PATIENTS USING INSURANCE

As a courtesy to its patients, Medical Group is pleased to assist in the submission of medical insurance claims to eligible insurance companies for payment. To the extent you have insurance that is accepted by Medical Group, by accepting this Agreement, you understand and acknowledge that:

  • You are hereby assigning to Medical Group all your right, title, and interest in any and all health insurance or other health care benefits payable to you or on your behalf by any insurance payer, private insurance and any other health plan for medical treatment rendered by Medical Group. The assignment will remain in effect until revoked by you in writing.

  • You also authorize direct payment to the Medical Group of all insurance benefits payable to you for such medical treatment. In the event an insurance payer pays you directly, you agree to immediately pay such amounts to the Medical Group.

  • Your medical insurance policy, if any, is a contract between you and your insurance company. It is your responsibility to know your benefits, and how they will apply to payment for the Services.

  • It is your responsibility to confirm that the provider that you see at Medical Group is a participating provider under your medical insurance policy.

  • Your insurance company may not cover 100% of the costs and fees associated with the Services, and you will be responsible for payment of any remaining balance due for the Services, including without limitation, for paying co-payments, deductibles, and any other costs and fees associated with the Services you receive that are not fully (or at all) covered by your insurance company.

  • It is your responsibility to provide Medical Group with appropriate and current medical insurance information, and to notify Medical Group immediately upon any change in your medical insurance coverage to ensure efficient claims billing and payment. In the event that you fail to provide all necessary and current medical insurance information, you understand that your insurance company may deny payment of claims relating to the Services, and you understand that you may be 100% responsible for the costs and fees associated with the Services.

  • You agree to allow Medical Group to disclose your information to the insurance plan you provided to Medical Group and any other health plan that pays for the cost of your medical or health care services now or in the future, for the purposes of Medical Group obtaining reimbursement for the services provided to you or otherwise communicating with the health plan regarding payment for services (the “Authorization”). This disclosure may include all health information pertaining to your medical history, mental or physical condition, and treatment and services received, including demographic information. This Authorization is valid until you are no longer a patient of the Medical Group, within five (5) years from the date you accept these terms, or applicable state law, whichever is earlier. You understand that you have the right to revoke this Authorization, in writing, at any time by sending such written notification to the Medical Group to the address provided in the Notice of Privacy Practices.

  • It is your responsibility to have obtained any and all necessary referrals and authorizations required prior to receiving the Services from the Medical Group. If your insurance company requires a referral and you do not have one, then you understand that you will be responsible for all of the cost and fees associated with the Services you receive.

  • If your medical insurance requires a co-pay, the co-pay is required at the time the Service is rendered.

To the extent you have insurance accepted by Medical Group, accepting this Agreement, you further hereby authorize payment of all medical insurance benefits which are payable to you under the terms of your medical insurance policy to be paid directly to Medical Group for the Services rendered.

SELF-PAYMENT FOR SERVICES

Services provided by Medical Group that are not covered by your medical insurance are 100% self-pay by our patients.
Accepting this Agreement, to the extent applicable, you understand and acknowledge that:

  • You are electing to purchase the Services on a self-pay basis either because you do not have medical insurance, Medical Group does not accept your medical insurance, your medical insurance does not cover the selected Services, or you elected not to use your medical insurance for your Services.

  • You have been given a choice of the Services provided by the Medical Group, along with their costs.

  • You have selected the Services and you are willing to accept full financial responsibility for timely payment of the Services.

  • You have selected the Services for purchase from Medical Group on a self-pay basis. In other words, to the extent you have medical insurance, you have directed Medical Group to treat your purchase of the Services as if you were an uninsured patient because these Services are not covered by your medical insurance or you elected to to use your medical insurance for such Services, and you therefore agree to be 100% responsible for full timely payment of the listed price of the Services as set forth in the Fee Schedule below.