This agreement and disclosure statement covers your account with us. In this agreement, the words “you” and “your,” mean the patient, or the patient’s spouse, or the parent or legal guardian or a minor patient, or any other person financially responsible by law for the patient’s medical care. The words “we”, “our”, and “us” mean A Better Tomorrow (ABT).

Promise to Pay: You hereby assign and authorize to A Better Tomorrow direct payment or other benefits to which you or the Patient may be entitled from any government agency or program, insurance company, or other entity that is or may be liable for costs associated with the Patient’s care. Should your insurance company pay you directly, you agree to endorse the payment over to ABT. As to any such payments received by ABT, it may give receipts and otherwise acknowledge payments on your behalf. You agree that this assignment will not be withdrawn or voided at any time until Patient’s account is paid in full. To the extent such authorization is required by applicable regulations, you hereby authorize ABT or any holder of medical information about the Patient to release such information to the Centers for Medicare and Medicaid Services and its agents as necessary to determine benefits payable for services provided to the Patient. For Medicaid members, Medicaid is considered payment in full and members will not be charged additional fees.

This authorization shall not modify or limit the Patient’s rights to use or disclose protected health information as otherwise allowed by applicable law or ABT Notice of Privacy Practices. You agree that you are responsible for any co-payments, deductibles, or other charges for services to you that are not paid by insurance, government programs, or other payers, except as prohibited by applicable law or any agreement between your insurance and ABT. You agree to make such payments according to ABT regular terms of payment. Where appropriate, you agree to submit and cooperate with ABT in submitting claims to entities from which payment may be obtained, including any government program, insurance company, or other third party. If your account becomes delinquent, you agree to pay interest and fees according to ABT’s policies. You agree that any overpayments collected for your treatment on this occasion may be applied directly to any delinquent account of yours.

Monthly Statements: Each month we will send you a statement showing any charges and payments or credits made to your account during that billing cycle as well as your “Current Balance.” Your statement will also identify any payment agreement amount you make with us.

Finance Charges: A finance charge will begin accruing on accounts not covered by insurance 60 days after the first billing. If your account is pending payment by insurance, the finance charges will begin accruing on the self-pay balance 60 days after the insurance pays. If your insurance company does not pay within 60 days after billing, the account will be considered a self-pay account, and interest will begin accruing on the full balance 60 days later. The periodic rate will be 1.5% per month, which corresponds to an Annual Percentage Rate of 18%. The finance charge will be figured by applying the periodic rate to the Average Daily Balance. The minimum finance charge for any balance is $5.00.

Balance Subject to Finance Charge: The balance subject to finance charge is identified on your monthly statement as the “Average Daily Balance”, which is the sum of the daily balances (beginning balance plus new charges less payments and adjustments) for each day of the billing cycle, divided by the number of days in the billing cycle.

Agreement Amount: For extended payment options, a minimum monthly payment may be arranged. This amount will be listed as the “Current Amount Due” on the monthly statement. Until agreement is made, the “Current Amount Due” on the monthly statement will show the full balance. The payment agreement amount may be modified by mutual consent of both parties. If you miss a payment, or if you break any other promise you have made under this agreement, we may declare your entire balance due and payable at once without notice or demand. We may also do this if you have made misrepresentations to us in applying for credit, or if anything happens that indicates to us that you may be unwilling to repay the amounts due under this agreement.

Change of Address: If you move, you must give us your new address so we can change our records. You agree to call or write your new address on your monthly statement returned with your payment and indicate a change of address by marking the appropriate notification on payment slip.

Attorney’s Fees and Costs: If we are forced to take collection action or any other legal action under this agreement, you agree to pay all court and collection costs, reasonable attorney’s fees, and all similar costs of appeal.

Cancelling This Agreement: We may terminate this agreement if you break any of your promises, or you are in default under this agreement. Upon termination or default, you agree to pay your entire balance due. You may terminate this agreement by paying the outstanding balance of your account in full.

A Better Tomorrow complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

SPANISH: A Better Tomorrow cumple con las leyes federales de derechos civiles aplicables y no discrimina por motives de raza, color, nationalidad, edad, discapacidad, o sexo.