Provider Name: [PROVIDE_NAME]
Patient Name: [PATIENT_NAME]
SERVICE: [EXAM_NAMES] (“Service”)
This constitutes a valid and binding agreement among the parties (“Agreement”).
The Patient or his/her authorized representative used LabFinder.com or its mobile app to find and book the services he/she needs at an agreed upon price.
The Provider agrees to provide to the Patient the above Service for a total self pay payment price of: $[TOTAL_CHARGE]. The Provider accepts such price (the “Service Charge”) due it as payment in full.
Patient further agrees to pay LabFinder $[CONVENIENCE_CHARGE] for its technological facilitation herein (the “Convenience Charge”).
Patients are charged for full balance of the Service Charge and Convenience Charge, respectively, at the moment the Provider accepts their bid. (See Cancellation and Refund Policy below)
THE SERVICE MUST BE OBTAINED NO LATER THAN [APPOINTMENT_DATE_TIME] OR THIS AGREEMENT WILL EXPIRE AND THE ABOVE PRICE WILL NO LONGER BE APPLICABLE FOR RENDERING OF THE SERVICE. UPON EXPIRATION, A NEW PRICE LOCK-IN REQUEST MAY BE SUBMITTED VIA LabFinder.
Service Charge includes the total rate for the listed Service above and is inclusive of all costs incurred by the Provider in rendering such service. However, additional record copying charges by the Provider may further apply and be separately charged by Provider.
EACH OF PROVIDER AND PATIENT REPRESENT, WARRANT AND COVENANT THAT THEY WILL NOT SUBMIT ANY BILLS OR CLAIMS FOR PAYMENT OR REIMBURSEMENT TO ANY PRIVATE OR GOVERNMENTAL PAYOR OR CARRIER FOR THE SERVICE RENDERED HEREIN.
This arrangement is only for the above-named Patient for the stated Service with the above-named Provider.
If the actual service or product required to treat the patient is different from that listed above, then Provider must inform Patient what the new/additional service or product is and what the price will be before rendering testing or treatment.
If the Service is billed in several parts or from different sources, the total Service Charge will nevertheless add up to the agreed upon Service price above. Provider will hold Patient harmless from and against any attempt (successful or otherwise) by a third party source to collect any excess amounts resulting in additional payment obligations by the Patient beyond the total Service Charge pricing for the Service as set forth above (Note: This does not apply to amounts owed LabFinder by Patient hereunder).
Provider represents and warrants that it is fully qualified, credentialed, registered and otherwise licensed to render all Services agreed upon herein for the above Patient.
CANCELLATION AND REFUND POLICY:
All amounts agreed to paid hereunder are NON-REFUNDABLE.
FURTHER ACKNOWLEDGMENTS AND AGREEMENTS:
- “LABFINDER, LLC” (“LabFinder”; sometimes “we”, “our” or the like) is inclusive of LabFinder.com and all associated websites and mobile applications (apps).
- If Patient cancels or disputes a charge or payment except as otherwise permitted under this Agreement, each of LabFinder and Provider respectively shall be entitled to reimbursement from Patient and the undersigned (as a legal representative and signatory hereto if different than Patient) of all collection costs including attorneys’ fees associated with recovering payment owed hereunder.
- LabFinder is acting solely as an intermediary facilitating the scheduling of services provided by third party providers, through technological means.
- LabFinder has no responsibility whatsoever for any claims against or adverse effect on the Provider or its professionals under this self pay arrangement. This includes, without limitation, if the Provider or its professionals are in-network with the particular insurance or other payor program or plan (including private and governmental) with which the Patient participates as a beneficiary. Similarly, we have no responsibility to the Patient if there is an alternative provider whose qualifications or specialties or participation match those required to treat the individual Patient on an in-network and otherwise participating provider basis.
- LabFinder makes no assurance at all as to whether or not the agreed upon pricing for the Service is the best possible price or is competitive or fair at the time of the rendering of the Service, and the Patient is advised that he/she may possibly pay less (taking into account any co-payment and deductible, or co-insurance obligation, as applicable) if he/she sought such service through his/her own insurance coverage or other payor program or plan (including governmental).
- LabFinder will not be performing any claims adjustment services or auditing the performance of Services. LabFinder will not be pursuing any collection against the Patient on behalf of Provider. Payments are due in advance through mechanisms arranged for by LabFinder. LabFinder will not be handling any disputes between the Patient and the Provider, whether regarding payment, the provision of the Service or otherwise. The Patient and Provider are solely responsible for ensuring/seeking/settling as between themselves any issues and disputes including those relating to the provision of a Service and quality of care. BOTH OF SUCH PARTIES AGREE TO COMPLY WITH THE ABOVE CANCELLATION AND REFUND POLICIES.
- Each of Patient and Provider hereby expressly acknowledge and agree that we are: (i) a technology development and platform company; (ii) not an insurance company, benefit plan or third party administrator and are not determining any patient’s eligibility to receive benefits under any third party payor program or plan (private or governmental); and (iii) for purposes of the Employee Retirement Income Security Act of 1974 (“ERISA”) or any equivalent or similar other state or federal laws/regulations that may be applicable, we shall not be deemed the “administrator” or “named fiduciary” of any benefit program or plan.
- Patients shall look solely to Provider for refunds owed of all or any portion of the Service Charge in all instances and circumstances, but subject to the terms hereof. Patients shall look solely to LabFinder for refunds owed of all or any portion of the Convenience Charge in all instances and circumstances, but subject to the terms hereof.
- LabFinder HAS NO LIABILITY WHATSOVER FOR ANY INJURY, DAMAGE, DEATH, LOSS, ACCIDENT OR DELAY DUE TO ANY FAULT, ACT OF NEGLIGENCE, OMISSION OR DEFAULT OF THE CONTRACTING PROVIDER OR PATIENT. IN NO EVENT SHALL LabFinder BE LIABLE TO EITHER PATIENT OR PROVIDER FOR LOSS OF GOODWILL, OR FOR SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL OR PUNITIVE DAMAGES ARISING OUT OF OR RELATING TO THIS AGREEMENT, THE PRICING AGREED UPON AND THE SERVICES SOUGHT OR RENDERED, REGARDLESS OF WHETHER SUCH CLAIM ARISES IN TORT OR IN CONTRACT.
- We may assign this Agreement to any successor to our business or assets to which this Agreement relates.
- We are deemed a party to this Agreement for purposes of enforcing our rights, the agreements and protections favoring us herein. If an applicable jurisdiction determines we are not a direct party, then we shall instead be deemed a third party beneficiary of this Agreement for the same purposes.
- Each party represents and warrants that it is duly authorized and has full power, capacity and authority to accept this Agreement on behalf of such party, including the above named Patient or Provider. If the person agreeing hereto is the legal representative of the Patient, such legal representative represents and warrants to the parties hereto that he/she/it is fully authorized to enter into this Agreement on behalf of the Patient and such legal representative hereby further becomes a party hereto and fully bound hereby as if the Patient party.
- By clicking below, entering into this agreement and otherwise using the LabFinder website/app, each of Patient and Provider accept these terms and conditions as a fully enforceable agreement.
MEDICARE-RELATED MATTERS: Beneficiary or his/her legal representative agrees to, understands and expressly acknowledges the following:
___ Beneficiary or his/her legal representative accepts full responsibility for payment of the Provider’s charge for all Services furnished, as well as any charges for cancellation as set forth herein.
___ Beneficiary or his/her legal representative understands that Medicare limits may or do not apply to what is charged hereunder.
___ Beneficiary or his/her legal representative agrees not to submit a claim to Medicare or to ask the Provider or any third party to submit a claim to Medicare.
___ Beneficiary or his/her legal representative understands that Medicare payment and reimbursement will not be made for any items or services furnished hereunder even if they would have otherwise been covered by Medicare if there was no private pay contract and a proper Medicare claim had been submitted.
___ Beneficiary or his/her legal representative enters into this contract with the knowledge that he/she has the right to obtain Medicare-covered items and services from physicians and practitioners, and the beneficiary is not compelled to enter into private contracts.
___ Beneficiary or his/her legal representative understands that Medi-Gap plans do not, and that other supplemental plans may not make payments for items and services not actually paid for by Medicare. Beneficiary or his/her legal representative agrees never to submit such claims or request or cause any third party to do so.
___ Beneficiary or his/her legal representative acknowledges that the beneficiary is not currently in an emergency or urgent health care situation.
___ Beneficiary or his/her legal representative acknowledges that a copy of this contract has been made available to him/her.
By your acceptance below, you acknowledge that you have read and understand this notice.
Created on Date Time : [DATE_TIMESTAMP]