www.aimergency.org 

Office: 561-231-2594 

Text: 561-231-0536

Purpose: This Assignment of Benefits (AOB) policy is established to define the terms and conditions under which patients may assign their insurance benefits to Aimergency Connect (Psych)Care ("Provider") for the purpose of facilitating the payment of services rendered.

Definitions:

1. Patient: Refers to the individual receiving healthcare services from the Provider.
2. Provider: Refers to Aimergency Connect (Psych)Care, the healthcare facility or professional rendering services to the patient.
3. Assignee: Refers to the Provider or any authorized representative designated by the Provider to receive and manage assigned insurance benefits on behalf of the patient.
4. Insurance Carrier: Refers to the patient's health insurance company or plan administrator.

Policy Statement:

Assignment of Benefits: Patients have the option to assign their insurance benefits to the Provider by completing and signing the Assignment of Benefits form provided by the Provider. By doing so, the patient authorizes their insurance carrier to make payments directly to the Provider for

covered services.

Scope of Assignment: The assignment of benefits applies only to healthcare services provided by the Provider and covered under the patient's health insurance policy. The patient may choose to assign benefits on a per- claim basis.

Patient Responsibility: The patient is ultimately responsible for ensuring that their insurance benefits are assigned correctly and that any remaining balance, not covered by insurance, is paid in accordance with their financial agreement with the Provider.

Changes to Assignment: Patients have the right to revoke or modify their assignment of benefits at any time by providing written notice to the Provider and their insurance carrier. Such changes will be effective as of the date the notice is received.

Provider's Obligations: The Provider agrees to:

• Bill the insurance carrier for covered services on behalf of the patient.
• Accept payments made by the insurance carrier as payment in full for services covered under the assignment.
• Provide patients with information related to their insurance claims and benefits upon request.

Authorization: Patients understand and authorize the release of medical and billing information to their insurance carrier for the purpose of processing claims related to the assigned benefits.

Compliance: This policy complies with all applicable state and federal laws governing Assignment of

Benefits.

Policy Review: This Assignment of Benefits policy will be reviewed periodically and updated as necessary to remain compliant with current laws and regulations.

Contact Information: For questions or concerns regarding this policy, please contact Aimergency Connect (Psych)Care.

At Aimergency Connect (Psych) Care, we are committed to providing high-quality healthcare services

with compassion, respect, and dignity. We believe that patients have certain rights and

responsibilities to ensure a positive and collaborative healthcare experience. This Bill of Rights and Responsibilities outlines the expectations for both patients and our healthcare team.

Patient Rights:

1. Quality Care: You have the right to receive appropriate and effective healthcare services delivered with the highest standards of professionalism.
2. Respect and Dignity: You have the right to be treated with respect, dignity, and without discrimination, regardless of your age, race,gender, religion, sexual orientation, or any other characteristic.
3. Privacy and Confidentiality: Your personal and medical information will be kept confidential and only disclosed as required by law or with your consent.
4. Informed Consent: You have the right to receive clear, understandable information about your diagnosis, treatment options, risks,and benefits, and to make informed decisions about your care.
5. Access to Information: You have the right to access your medical records and receive an explanation of your billing and charges.
6. Complaints and Grievances: You have the right to express concerns, complaints, or grievances about your care without fear ofretaliation and to receive prompt and respectful responses to your concerns.

Patient Responsibilities:

1. Honest Communication: Provide accurate and complete information about your medical history, symptoms, and any other relevant information to help us provide the best care.
2. Follow Treatment Plans: Comply with the treatment plan recommended by your healthcare provider and follow prescribedmedications and therapies as directed.
3. Respect for Others: Treat all healthcare providers, staff, and fellow patients with respect and courtesy.
4. Punctuality: Arrive on time for appointments, or if unable to attend, provide advance notice of cancellation or rescheduling.
5. Financial Responsibility: Understand and fulfill your financial obligations, including payment of co-pays, deductibles, or othercharges in accordance with the agreed-upon terms.
6. Safety: Follow safety guidelines and policies while in our care, including those related to the use of medications, medical equipment,and behavior within our facilities.
7. Feedback: Provide feedback on your care experience and any concerns you may have. Your input helps us improve our services.

Discharge Planning:

If discharge from our care is recommended, you have the right to be involved in your discharge planning and toreceive information about post-discharge care and follow-up.

Protection of Vulnerable Patients:

We are committed to safeguarding the rights of vulnerable patients who may be unable to fullyexercise their rights. We will advocate on behalf of these patients and ensure their rights are protected.

Policy Review:

This Bill of Rights and Responsibilities will be reviewed periodically to remain current with evolving healthcare practices and patient needs.

Contact Information:

If you have questions or concerns related to this policy, please contact Aimergency Connect (Psych) Care.

I acknowledge that I have read and understand this Bill of Rights and Responsibilities - Patient Policy.

1. Consent: I voluntarily consent to this service(s) to Aimergency Connect Psych Care

2. Emergency Treatment and/or Hospital Transfer: I understand while at Aimergency Connect Psych Care, the need for emergency treatment and/or transfer to a hospital may become necessary and appropriate. Should the need for such treatment and/or transfer be deemed necessary and appropriate by my attending physician, their assistants and designees, I consent to such emergency treatment

and/or transfer to a hospital and indemnify Aimergency Connect Psych Care and its staff, or any physician who may be in attendance,

from any loss resulting from such emergency treatment and/or transfer.

3. Medical Consent: The Client is under the care of their attending physician, or the physician assigned by Aimergency Connect Psych Care, and the undersigned consents to examination and laboratory procedures. Medical treatment is rendered under the order of the physician, or his

designee.

4. Consent for Labs: I understand I may be requested to provide a urine or blood sample upon admission, randomly, upon suspicion of drug or alcohol use, or at the request of any staff member, including but not limited to the physician, nurse practitioner, or physician assistant for

treatment planning purposes. I hereby acknowledge these protocols and consent to the administration

of any lab test requested. I also understand that these tests may or may not be covered by insurance and carry an extra cost which will be passed on to me for payment.

5. Conditions of Treatment: I acknowledge and understand that the practice of substance abuse treatment is not an exact science and that there are no promises or guarantees have been made to me regarding the final outcome of my treatment by Aimergency Connect( Psych) Care, and I do hereby absolve Aimergency Connect Psych Care from any liability in the event its treatment of my person isunsuccessful either in the short or long term or any events that may due to my addiction and/or treatment.

6. Rules & Regulations: I hereby agree to comply with and abide by the policies, rules, and regulations of Aimergency Connect (Psych) Care during my treatment.

7. Release of Information: I understand that Aimergency Connect (Psych)Care may disclose any part or all of my medical record to any person or corporation which is or may be liable under a contract to Aimergency Connect Psych Care, or the Client, or to a family member of the Client, including all or part of the facility charges. Aimergency Connect Psych Care may further disclose all or said part

of theClient’s record to the referring doctor, hospital, or clinic.

8. Personal Valuables: Aimergency Connect Psych Care shall not be liable for the loss or damage to any money, jewelry, eyeglasses, contact lenses, dentures, documents, or other articles of value of which is not placed in the safe.

9. Drugs: I agree that I shall neither use, nor keep, any drugs or drug appliance/apparatus not prescribed by or on behalf of the attending physician. All medications should be dispensed / taken as directed by the physician during the Client’s current stay. Any such contraband found in the Client’s possession will be removed and destroyed.

10. Authorization for Treatment: I agree I have voluntarily enrolled in treatment at Aimergency Connect  Care and do hereby voluntarily consent to such care-encompassing procedures and treatment by Aimergency Connect Care that it’s Director,

employees, staff physician and designees deem necessary in their judgment.

11. Intern Disclosure: I understand that some services may be provided by an alcohol and drug counselor intern, social work or other discipline intern, under the clinical supervision of a qualified clinical supervisor. The clinical supervisor will oversee the treatment provided in such

cases.

In consideration of the acceptance of the undersigned for voluntary care at Aimergency Connect

Psych Care, I do hereby waive, release and indemnify Aimergency Connect Psych Care, it’s officers, agents, employees and professional associates of all any kind of liability(legal, financial, medical, and otherwise) for any claim of loss or damages, because of any

injuries, direct or indirect which may occur to me or to my family or friends, or for loss, damage or theft of any of my personal property during my enrollment, whether or not the professional associates, and whether or not such injury, loss of damage occurs on or off the

premises or in or out of a vehicle, surveillance, or supervision of Aimergency Connect Psych Care, or its officers, agents, employees or professional associates.

I hereby certify that I am capable of mentally and physically sustaining my life.

The undersigned certifies to understand and agree to above, receiving a copy thereof, and is the

Client, or is duly authorized by and on behalf of the Client to execute the above and accepts its terms personally and upon the Client’s

behalf.