Consentimiento de Pago y Facturación

*  Esta traducción al español se proporciona únicamente para su conveniencia. En caso de cualquier discrepancia, prevalecerá la versión en inglés. Haga clic AQUÍ para ver la versión en inglés . 

Al hacer clic donde se indica, yo, el abajo firmante, acepto los términos descritos en este Acuerdo de Consentimiento de Pago y Facturación (“Acuerdo”). 

Esto incluye, pero no se limita a, (i) mi responsabilidad de los pagos si mi plan de seguro médico no cubre los cargos, (ii) el proceso de presentación de reclamaciones a cualquier Plan (definido a continuación), (iii) los requisitos para obtener referencias y (iv) las consecuencias de la falta de pago, incluidas las acciones de cobro y los cargos asociados.

Los términos en mayúsculas que no estén definidos de otro modo en este Acuerdo tienen el mismo significado que se establece en los Términos y Condiciones de Gentle Giant AT HOME ("Términos y Condiciones"), que se incorporan al presente por referencia.

1. Cesión de beneficios 

Al hacer clic donde se indica, yo, el abajo firmante, cedo irrevocablemente a My Essential Provider of Rhode Island, Alina Telehealth Serviced of Texas y otros grupos médicos afiliados con los que Gentle Giant AT HOME LLC pueda contratar (colectivamente, “Grupos Médicos”) y a cualquier proveedor contratado por un Grupo Médico, incluyendo, pero no limitándose a, médicos, enfermeros practicantes y asistentes médicos asignados a mí por Gentle Giant AT HOME LLC (colectivamente, “Proveedores”), todos mis derechos y beneficios y cualquier otro interés que tenga en cualquier plan de seguro médico, plan de beneficios de salud, plan de indemnización, fideicomiso, fondo u otra fuente de pago por servicios de atención médica (cada uno, un “Plan”) en relación con los servicios médicos proporcionados por los Grupos Médicos y sus respectivos Proveedores, empleados y agentes. Solicito y por la presente acepto que cualquier beneficio que me corresponda por mi tratamiento por parte de cualquier Plan se pague o se asigne al Grupo Médico correspondiente. Esto incluye cualquier acuerdo de la compañía de seguros relacionado con mi tratamiento. Si mi Plan no paga directamente al Grupo Médico por mi atención y tratamiento, enviaré inmediatamente los pagos que reciba al Grupo Médico. Entiendo y acepto que el envío de cargos a mi Plan no implica la renuncia al derecho de ningún Grupo Médico a reclamarme el pago directamente. Acepto que el Grupo Médico pueda facturarme cualquier cargo adeudado.

2. Planes contratados

I understand and agree it is my responsibility to understand my Plan benefits. If I have questions about my health insurance coverage or charges, I am responsible for asking them before products or services are provided. I understand and agree, except as provided in this Agreement or the Terms and Conditions, neither Gentle Giant AT HOME LLC, nor Medical Groups, Providers, Labs, or Pharmacies make any representations whatsoever that any fees are covered by my Plan. 

If and where I receive Services from Cloud Medical Group, and I am a federal health program beneficiary, I agree that neither myself, nor my Provider, nor Cloud Medical Group will submit a claim for reimbursement to any federal or state healthcare program for the costs of the services and products provided to you through the Services. 

3. Non-Covered Services

I understand that my Plan may not cover all my costs. Non-Covered Services shall refer to products or services provided by Medical Groups, Providers, Labs, or Pharmacies that are not covered by my Plan and are not considered a covered benefit under my Plan (“Non-Covered Services”). If any Medical Group, Provider, Lab, or Pharmacy does not participate in my Plan, or if my Plan does not cover the charges for my services, whether in full or in part, I understand and agree I will be financially responsible for any portion of the bill not covered by my Plan. 

I agree to be personally responsible for any costs not covered by my Plan or that exceed my benefit limits, including, but not limited to:

(i) self-administered medications (medicines I would normally take on my own);
(ii) certain durable medical equipment; 
(iii) certain medical supplies;
(iv) certain Non-Covered Services described in this Agreement; or
(v) services and supplies that my Plan determines are experimental or investigational or are not covered for some other reason, or that are not medically necessary but that I want to receive.

I understand and agree it is my responsibility to understand my Plan benefits. If I have any questions about my Plan coverage or charges, I am responsible for asking them before products or services are provided. I understand that, if my Plan requires a referral, I am responsible for obtaining one prior to my appointment.

I understand, except as provided in this Agreement or the Terms and Conditions, neither Gentle Giant AT HOME LLC nor Medical Groups, Providers, or Labs make any representations whatsoever that any fees are or are not covered by my Plan. Submission of charges to my Plan does not waive any Medical Group’s right to seek payment directly from me. Where applicable, 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 Plan, for any reason.

4. Subscription Fee

I understand and agree that any Gentle Giant AT HOME subscription fee is not a covered benefit under any health insurance plan and shall be considered a Non-Covered Service. My Plan will not be responsible for payment of the subscription fee nor any other Non-Covered Service(s). I understand and agree that I will be financially responsible for the subscription fee in whole. By purchasing a Gentle Giant AT HOME subscription, I agree to the payment terms as outlined in the Terms and Conditions and the offer terms presented during the checkout process. I understand that I may cancel my Gentle Giant AT HOME subscription in accordance with the Terms and Conditions.

5. Prescription Medications & Supplements

If I am prescribed and choose to purchase Prescription medications or Supplements through the Platform, I understand and agree that any charges and fees related to such medications are Non-Covered Services and my health insurance plan will not be responsible for payment of any such charges or fees. I understand and agree that I will be solely financially responsible for all charges and fees for said medications and I agree that I will not submit, nor cause any other party to submit a claim to my  health insurance plan for such amounts. I understand that I may contact Medical Group at any time at info@GentleGiantATHOME.com if I no longer agree to be financially responsible for charges and fees for said medications. However, if I do not agree to be financially responsible for said medications, the third-party Pharmacy will no longer provide said medications to me. Please refer to Section 9 of the Terms and Conditions for additional details regarding prescription products.

7. Laboratory Services

From time to time, Gentle Giant AT HOME may present me with a choice of certain laboratory services and their costs. By purchasing such laboratory services, I agree to pay Gentle Giant AT HOME for their Lab vendor services. If I choose to purchase laboratory services on a self-pay cash basis instead of utilizing my health insurance benefits. If I choose to self-pay for my  laboratory services, I understand and agree that Medical Group will treat my purchase of these services as if I am an uninsured patient and I agree to be solely responsible for full payment of the listed price of the services and neither I nor Medical Groups nor any third-party Labs, Pharmacies or Providers will submit any claim to any insurance plan for the services. The listed price of laboratory services includes amounts paid to third-party Labs and administrative fees paid to Gentle Giant AT HOME. Within a reasonable timeframe following Medical Group’s receipt of the results of your diagnostic labs, a Provider will review the results with you and answer any questions you may have.

8. Self-Pay Options

If I do not have health insurance coverage, or if any Medical Group, Lab or Pharmacy provides any product(s) or service(s) to me and does not participate in my health insurance plan, or if I choose to self-pay for any product(s) or service(s) for any reason, whether or not I have health insurance coverage, I agree to pay such Medical Group, Lab, or Pharmacy all applicable charges at the prices then in effect for the products or services provided to me, including any no-show fees where applicable In accordance with the Terms and Conditions, I hereby authorize Gentle Giant AT HOME to automatically charge my payment method for all such charges. If my payment method is invalid at the time payment is due, I agree to pay all amounts due upon demand. Please refer to the Terms and Conditions for additional details.

9. Payment and Collections

Gentle Giant AT HOME and Medical Groups accept credit and debit cards issued by U.S. banks. If a credit card account is being used for a transaction, Gentle Giant AT HOME and the Medical Groups may obtain preapproval for an amount up to the amount of the payment. If I enroll to make recurring payments automatically, all charges and fees will be billed to the credit card I designate during the setup process. If I want to designate a different credit card or if there is a change in my credit card, I understand that I must change my information online. This may temporarily delay my ability to make online payments while Gentle Giant AT HOME verifies my new payment information.

I hereby authorize the Medical Group or its designated agent to access my consumer credit report to help collect what I owe or to see if I am eligible for financial aid or charity care. In the event any collection action is necessary to collect amounts I owe to a Medical Group, Lab and/or Pharmacy, I agree to pay all expenses associated with such action, including but not limited to collection agency fees and attorneys’ fees. 

Where permitted by law, Medical Group and its providers, affiliates, agents and contractors, including debt collectors, may call or text my cell or home phone using any type of artificial or pre-recorded voice or auto-dialer technology for any purpose, including billing and collections.

Gentle Giant AT HOME reserves the right to charge any outstanding post-claim balances to the payment method on file. An invoice will be provided post-claim, with payment due within 15 days, at which point if payment has not been made yet, the card on file will be billed. If payment is unsuccessful, you will have an additional 30 days to resolve the balance before your subscription is terminated pursuant to the Terms of Service. Notification, where provided, is for your convenience and does not constitute an obligation on Gentle Giant AT HOME’s part. You agree that any post-claim balances due will be processed automatically, unless you contact Gentle Giant AT HOME’s support team to address any outstanding payment concerns prior to processing. 

Asimismo, usted acepta abonar una tarifa de treinta dólares estadounidenses (USD $30.00) («Tarifa por inasistencia») por cualquier consulta programada a la que no asista o cancele con menos de 24 horas de antelación. Esta tarifa se cargará al método de pago registrado.

10. Acuerdo

Al aceptar este Acuerdo de Consentimiento de Pago y Facturación, reconozco y acepto todos los términos y requisitos aquí estipulados. Asimismo, reconozco que mi firma digital u otra forma de aceptación de este Acuerdo se considerará tan efectiva y válida como una firma original.

Reconozco mi responsabilidad financiera por cualquier parte de la factura no cubierta por mi Plan y autorizo a Gentle Giant AT HOME y a los Grupos Médicos y Proveedores a presentar reclamaciones a mi Plan en mi nombre, cuando corresponda. También acepto pagar cualquier tarifa y costo asociado con productos o servicios que no estén cubiertos por mi Plan, incluyendo aquellos productos o servicios que decida comprar pagando en efectivo. Además, doy mi consentimiento para el uso de mi tarjeta de crédito o débito para transacciones de pago. Asimismo, autorizo al Grupo Médico y al Proveedor y/o a sus agentes a divulgar cualquier información médica o de otro tipo sobre mí que obre en su poder a mi Plan, a las agencias administrativas federales y estatales, o a sus intermediarios o agentes fiscales que se requieran o soliciten en relación con el procesamiento de cualquier reclamación por los servicios que me haya prestado el Proveedor.

He leído, comprendo y acepto este Acuerdo.