Patient Financial Responsibility

ACKNOWLEDGEMENT

I acknowledge and understand that:

1. I have advised WLC Medical that my treatment relates to either a Motor Vehicle Accident, Workers' Compensation or other compensable claim.
2. At the time of signing this acknowledgement, WLC Medical has not received satisfactory confirmation that my claim and/or the treatment I am attending has been approved for payment by the insurer or claims manager.
3. I understand that providing WLC Medical with a claim number, GP referral, Certificate of Capacity or other referral or claim documentation does not necessarily mean that my claim or treatment has been approved.
4. WLC Medical has advised me of the applicable fee for my appointment and that I am personally responsible for payment while funding remains unconfirmed.
5. I agree to proceed with treatment before WLC Medical has received satisfactory confirmation of funding.
6. I understand that I will be charged/invoiced at the applicable Motor Vehicle Accident or Workers' Compensation rate for the service while approval remains pending.
7. I understand that the insurer may subsequently decline my claim, decline the treatment, limit the amount payable or otherwise determine that some or all of the cost will not be reimbursed.
8. I understand that WLC Medical cannot guarantee that my insurer will reimburse me.
9. If my claim and relevant treatment are subsequently approved, I understand that I may be required to submit my invoices and/or receipts to my insurer or claims manager and request reimbursement directly from the insurer.
10. I remain responsible for amounts owing to WLC Medical unless WLC Medical confirms an alternative billing arrangement.

I confirm that I have had the opportunity to ask questions regarding these payment arrangements and agree to proceed with my appointment on this basis.