Policies And Disclosure

Definitions And Details

Patient Confidentiality Acknowledgement Statement

I understand that as a patient of Acqua Recovery, I may become aware of information relating to other patients. I understand that I cannot reveal or discuss any information regarding patients with anyone outside Acqua Recovery. This privacy protection afforded to me and others in treatment at Acqua Recovery are for my welfare and the welfare of others in treatment.

 

Federal Confidentiality Regulations 42 CRF Part 2 prohibits me from making any disclosures without specific written consent of the person to whom which disclosure pertains. A general authorization for the release of information (a general, medical or clinical) would not be sufficient.

 

I further understand that Act 63 contains no criminal penalties for breach of confidentiality. However, Federal Regulations cover such breaches and provide for the fine of $500.00 for the first offense. For each subsequent offense, the fine may be as high as $5,000.00.

 

I fully understand and am willing to adhere to the above statement. I am fully aware that my treatment and active status with this agency is contingent upon my adherence to this contract.

Acqua Recovery, LLC

FINANCIAL AGREEMENT

In compliance with commercial insurance regulations, arrangement for payment of co-payments and deductibles will be made at the time of admission. Please be advised that we bill your insurance company as a courtesy to you. Any remaining balances are your responsibility.

 

The following constitutes the financial policy of Acqua Recovery, LLC, hereafter called “Facility”, with respect to services rendered at this Facility.

 

Facility will bill insurance carriers on behalf of the Patient where applicable. This is a service we provide for our Patients. The Patient is still responsible for all charges incurred.

 

If insurance carrier fails to remit payment for services within 90 days and, the Patient will be billed for the balance on the account. All statements are due in full upon receipt.

 

Facility does not provide refunds of any monies paid by or on behalf of the Patient when the Patient leaves the facility against medical advice or for major rule violations.

 

Initial payment for treatment is due upon admission unless insurance assignments are accepted. Subsequent payments are due on the first day of each subsequent treatment period.

 

I understand that my records are protected under Federal Confidentiality regulations (42 J.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for Federal laws and 42 CFR Part 2 for Federal regulations) published August 10, 1987, and cannot be disclosed without my written consent unless otherwise provided in the regulations. I understand that my medical record may contain information concerning my psychiatric, psychological, drug or alcohol abuse, HIV/AIDS and/or related conditions.

Online Payment Policy:

To make an online payment, you will need:

Patient first name, last name and date of birth
Email address (for receipt confirmation)
Payment amount
Credit/debit card, or bank routing and account number

If you have any questions about the online payment process, or to make a payment over the phone, please call the Billing Office at the contact information below.

844.654.3700 ext 702
Monday through Friday
8 a.m. to 4 p.m.

You may also mail your payment to the address on your statement, or call the number above to make your payment over the phone.

If you are interested in setting up payment options, or if you have questions about an account in collections, please contact our billing office at the phone number above. Acqua Recovery accepts MasterCard, Discover, Visa or American Express credit and debit cards.

 

Cancelling/Voiding or Refunds of Payment Card Transactions

By using this site, you understand that all payments processed by Acqua Recovery LLC, are for healthcare related services you have, or will have in the future, which were or will be rendered at the facility.

Acqua Recovery may be listed on your credit/debit/HSA card statement for payments made through this website.  If you have questions, please contact our Billing Office at the telephone number listed below.

Acqua Recovery, may issue a requested refund on a credit/debit/HSA card payment for the following reasons:

  • The provider has requested us to refund your payment due to overpayment on the patient account, or due to an adjustment being posted to the patient account.
  • Customer transaction entry error, such as a payment being made for more than intended ($500.00 instead of $50.00)
  • Duplicate Payment

We will do our best to resolve your request within 1 week of the request being submitted, there may be a delay in processing a refund if the request is received on a Friday or holiday.

 

Cancelling, Voiding or Refund of Payment

When requesting to cancel, void or refund of your card payment, or any portion thereof, please have the following information available to make the process as easy as possible:

  • Your Name
  • The Date and Time the payment was made through this website or by phone
  • Your Payment Authorization Code provided at the end of a successful payment
  • The last four (4) digits of the card used to make the payment
  • The Statement ID for which the payment was made

Failure to provide this information could slow the refund process.

All payments submitted through this website or by phone will be processed at 12:00 AM (Midnight).  Any request to cancel or void a payment received by 3:00 PM the date the payment was made may be processed within 1 week.

An approved refund may be initiated by our office within 1 week of the refund request being submitted, unless that request is received on a Friday or holiday. Please keep in mind that although the refund has been initiated by our office as outlined, your card issuer has control over when the refunded amount may be applied as a credit to your card balance.