Financial Responsibility Agreement

Please read carefully. This agreement explains the cost of your care and how balances are paid.

This Financial Responsibility Agreement (“Agreement”) is between you (the “Patient,” “you,” or “your”) and Grata Health Care P.C. and its affiliated medical groups (collectively, “Grata Health”). It describes your financial responsibility for the services you receive and your authorization for how balances are paid. By signing below, you agree to its terms.

1. Insurance and assignment of benefits

If you provide insurance information, Grata Health will submit claims to your insurance plan on your behalf. You authorize your insurance plan to pay benefits directly to Grata Health. You are responsible for providing current, accurate insurance information and for notifying Grata Health promptly of any change. You understand that having insurance does not guarantee that every service is covered.

2. Your financial responsibility

You are responsible for all amounts your insurance plan does not pay. These patient-responsibility amounts include:

• Copays due at the time of service;
• Coinsurance and deductible amounts determined after your insurance processes the claim;
• Charges for services that are not covered by your insurance plan; and
• Any outstanding balance on your account.

If you do not have insurance or choose not to use it, you are responsible for the full cost of your services as a self-pay patient. Grata Health can provide self-pay pricing on request.

3. When payment is due

Copays are due at the time of service. Other patient-responsibility balances are due when billed, after your insurance has processed the claim. Grata Health will send you a statement or notice for amounts you owe.

4. Card on file authorization

Grata Health is a virtual practice and does not collect payment in person. When you enroll, you provide a payment card as part of the intake process. By signing this Agreement, you authorize Grata Health to keep that card securely on file and to charge it for the patient-responsibility amounts described in Section 2 once they are determined, including:

• Copays due at the time of service;
• Coinsurance and deductible amounts after your insurance processes the claim;
• Balances for services not covered by your insurance plan; and
• Any outstanding patient balance on your account.

You further understand and agree that:

• Your card information is collected and stored securely by Grata Health’s payment processor in compliance with the Payment Card Industry Data Security Standard (“PCI DSS”). Grata Health does not store your full card number in its own records.
• Grata Health will send you a receipt or notice for each charge made to your card on file. Where the exact amount is not known until your insurance processes the claim, Grata Health will charge your card after the claim is adjudicated.
• This authorization applies to the card you provided at intake and to any replacement or updated card you provide.
• You certify that you are the cardholder or are authorized to use the card you provide.

5. Payment methods and plans

You may also pay in your patient portal at app.grata-health.com or by phone. If a balance is a hardship, Grata Health may offer a payment plan. Please contact us to discuss options before a balance becomes past due.

6. Declined cards and past-due balances

If your card on file is declined or you have no valid card on file, you remain responsible for paying your balance by another method. Grata Health may pause non-urgent services until your account is current, consistent with applicable law and your continuity of care.

7. Missed appointments and returned payments

Grata Health may charge a fee for missed appointments or late cancellations, and for returned or failed payments, as disclosed in its current policies. Any such fees are your responsibility.

8. Duration and revocation of card authorization

The card on file authorization in this Agreement remains in effect until you revoke it in writing by contacting Grata Health at care@grata-health.com or (757) 866-3806. Revocation does not apply to charges already incurred or in process. Revoking the authorization does not change your responsibility to pay your balances by another method.

9. Acknowledgment

I have read and understand this Financial Responsibility Agreement. I agree to be financially responsible for the amounts described above, and I authorize the card on file charges as described. I enter into this Agreement voluntarily.