Healthcare Disconnect Policy

HEALTHCARE DISCONNECT POLICY

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History (Brief)

Scope and Purpose of Policy

This Healthcare Disconnect Policy sets forth the circumstances, procedural requirements, and patient rights related to the discontinuation or suspension of non-emergent clinical services, elective care, or routine access to the practice for reasons including but not limited to nonpayment, repeated failure to attend scheduled appointments, failure to follow prescribed treatment plans, termination or lapse of insurance coverage, or submission of fraudulent or materially incomplete information. Emergency and urgent care obligations of the provider are governed by law and are not eliminated by this policy.

Grounds for Disconnect

The provider may discontinue or suspend non-emergent services for any of the following reasons. Patient acknowledges that the following are valid grounds under this policy and that the practice will follow the notice and appeal procedures set forth below prior to disconnecting care when legally required:

Nonpayment of patient financial responsibility after written notice and the opportunity to cure standard billing disputes.

Repeated missed appointments or failure to attend scheduled visits without timely cancellation as defined in practice scheduling rules.

Failure to comply with essential components of an agreed treatment plan that materially impairs the provider's ability to deliver safe care.

Termination or lack of verification of insurance coverage when coverage is a condition of service and no satisfactory alternative payment arrangement is reached.

Fraudulent, abusive, or threatening behavior by the patient or a patient representative that jeopardizes staff or other patients.

Notice and Cure Periods

Except in circumstances involving immediate danger to staff or other patients or where state or federal law permits immediate termination, the provider will: (a) deliver a written notice specifying the reason for proposed disconnect, the effective date of proposed disconnect, and the steps required to cure the condition; (b) provide a minimum cure period of ten (10) calendar days from the date of mailing or hand delivery of notice for payment or corrective action; and (c) attempt to contact the patient by the contact information on file prior to effectuating service suspension.

Preferred notice methods (select all that apply):
Mail    Email    Telephone call / voicemail

Emergency and Urgent Care Exceptions

The practice will not refuse or disconnect services required for emergency stabilization or other services mandated by applicable law to preserve life or prevent serious harm. Nothing in this policy limits the patient's right to seek emergency services in any suitable facility.

Appeals and Reinstatement

A patient may appeal a proposed disconnect by submitting a written request for review to the practice within five (5) business days of receiving notice. The appeal request must state the grounds for disagreement and include supporting documentation. While an appeal is pending, the practice may agree to suspend the disconnect pending resolution when doing so is reasonable and does not create an imminent risk of harm. Reinstatement of services following disconnect is conditioned on resolution of the underlying issue and may require a written reinstatement agreement and payment of past-due amounts where applicable.

Patient Financial Responsibility

The patient is responsible for payment of co-payments, deductibles, co-insurance, and charges not covered by insurance as set forth in the practice's billing policies. Nonpayment of patient-responsible balances, after notification and the opportunity to cure or enroll in a reasonable payment arrangement, may be grounds for suspension of non-emergent services.

Privacy, Confidentiality, and HIPAA Acknowledgment

The practice will communicate notices required under this policy in a manner consistent with privacy obligations. By signing below, the patient acknowledges receipt of the practice's privacy notice and authorizes the practice to use the contact information on file to provide notices related to billing, coverage, and service continuation. The patient's medical record will be handled in accordance with applicable privacy and security laws.

Acknowledgments (select each to indicate understanding):

I have received, read, and understand the Healthcare Disconnect Policy.

I understand my financial responsibilities and that failure to meet them may result in suspension of non-emergent services in accordance with this policy.

I acknowledge receipt of the practice's privacy notice and authorize contact as described above.

Complaint / Contact Information

If you believe a disconnect notice or action was made in error, you may submit a written complaint to the practice. Please provide a brief description of the complaint and desired resolution below.

Sign Now