Note The Clinic may select multiple payment options or restrict the accounts payable to only – one option. Please initial the methods that are accepted or declined. If you choose to change the methods of payment in the future, you must this submit a new signed and dated Account Authorization & Billing Agreement, the previous Agreement shall remain in force until the new Agreement is received by Dunwoody Labs. Payment Initial Initial Method Description Accept Decline Clinician A valid Clinic credit card must be on file and the card will be Pay charged when the test is released to the Clinician Portal. A valid Patient credit card information or check must be received Patient with the Test Requisition. The patient credit card will be charged Pay immediately upon receipt. In the event the credit card is declined, the Report will NOT be uploaded to the Client Portal until full payment is received. The Patient agrees to allow Dunwoody Labs, Inc. to bill the and the Patient (or the Clinician on the Patient’s insurance carrier behalf) must provide a valid credit card or include a check Patient’s with the sample for the Simple Pay price as shown in the most recently published Test Price List. In addition, the Patient must submit valid insurance cards that meet the following criteria: Simple Pay Insurance is NOT with Medicare or Medicaid or other insurance carrier not accepted by Dunwoody Labs (see full list below) The insurance deductible does NOT exceed $2,000. patient’s In the event the above criteria are NOT met, the Patient will be charged the Patient Pay Price as listed in the most recently published Test Price List. Upon Dunwoody of insurance benefits, prepayments Labs’ receipt will be applied to the Patients deductible and co-insurance. NOTE The Insurance Only option must be approved in advance by Dunwoody Labs. Please – note that if this option is selected, NONE of the other options may be selected. The Clinician and Patient grant Dunwoody Labs, Inc. the right to file for the insurance benefits on behalf of the Patient. The Patient’s Insurance insurance must meet the same criteria as the Simple Pay plan noted Only above. In the event the insurance does not meet the stated patient’s criteria, the Clinic will be billed for the test at the Clinician Price as most recently published in the Test Price List. Dunwoody Sales Representative
Note – The Clinic may select multiple payment options or restrict the accounts payable to only one option. Please initial the methods that are accepted or declined. If you choose to change the methods of payment in the future, you must this submit a new signed and dated Account Authorization & Billing Agreement, the previous Agreement shall remain in force until the new Agreement is received by Dunwoody Labs. Payment Method Description Initial Accept Initial Decline Clinician Pay A valid Clinic credit card must be on file and the card will be charged when the test is released to the Clinician Portal. Patient Pay A valid Patient credit card information or check must be received with the Test Requisition. The patient credit card will be charged immediately upon receipt. In the event the credit card is declined, the Report will NOT be uploaded to the Client Portal until full payment is received. Simple Pay The Patient agrees to allow Dunwoody Labs, Inc. to bill the Patient’s insurance carrier and the Patient (or the Clinician on the Patient’s behalf) must provide a valid credit card or include a check with the sample for the Simple Pay price as shown in the most recently published Test Price List. In addition, the Patient must submit valid insurance cards that meet the following criteria: Insurance is NOT with Medicare or Medicaid or other insurance carrier not accepted by Dunwoody Labs (see full list below) The patient’s insurance deductible does NOT exceed $2,000. In the event the above criteria are NOT met, the Patient will be charged the Patient Pay Price as listed in the most recently published Test Price List. Upon Dunwoody Labs’ receipt of insurance benefits, prepayments will be applied to the Patients deductible and co-insurance. NOTE – The Insurance Only option must be approved in advance by Dunwoody Labs. Please note that if this option is selected, NONE of the other options may be selected. Insurance Only The Clinician and Patient grant Dunwoody Labs, Inc. the right to file for the insurance benefits on behalf of the Patient. The Patient’s insurance must meet the same criteria as the Simple Pay plan noted above. In the event the patient’s insurance does not meet the stated criteria, the Clinic will be billed for the test at the Clinician Price as most recently published in the Test Price List. Dunwoody Sales Representative
Account-Authorization-and-Billing-Agreement-040617.docx