Financial Policy Acknowledgment
Private, self-pay telemedicine practice
The practice does not participate with or submit claims to commercial insurance, Medicare, Medicaid, Medicare Advantage, or other third-party payers. The patient is responsible for all charges. However, upon request, TexasCURT will provide the correct ICD-10 codes required by all insurers so that a patient may submit a claim to an insurer.
TexasCURT does not guarantee that any insurer will reimburse a patient for the cost of Dr. Rivers’ services.
Payment is due AT SCHEDULING .
| Service | Fee |
| Initial physician consultation | $175.00 |
| Scheduled follow-up consultation | $75.00 |
| Extended or additional consultation, if offered | $350.00/HOUR |
| Late cancellation / missed appointment | PAYMENT FORFEITED |
| Medical-record copy or administrative service | As permitted by law / $15.00 |
The practice requires payment through its secure payment system.
Payment is required at the time of making an initial or a follow-up appointment.
Charges from dispensing organizations, laboratories, imaging providers, consultants, pharmacies, or other third parties are separate and are not included in charges from TexasCURT.
Cancellation and rescheduling:
Appointments canceled or rescheduled with less than 24 hours’ notice, and missed appointments, result in forfeiture of the fee paid. Exceptions may be made for emergencies or reasonable circumstances accepted by the practice. Examples of such circumstances include hospitalization or hospital Emergency Department visits encompassing the time of the scheduled TexasCURT appointment, unavoidable or emergent situations requiring the patient to attend to the needs of close family members, documented conflicting appointment with another physician, and situations deemed appropriate by the patient’s primary care or specialist physician and explained in writing or by physician call to Dr Rivers at 254-441-7723.
Patients who are late to an appointment with Dr Rivers may receive a shortened visit or may need to reschedule at Dr Rivers’ discretion.
Payment is for the physician’s time, evaluation, medical decision-making, and related professional services—not for a guaranteed diagnosis, acceptance, CURT eligibility, prescription, certification, or outcome. A fee is not refundable merely because treatment is not recommended or a prescription is not issued.
At the patient’s request, the practice may provide a receipt or statement of services including ICD-10 diagnosis codes. The practice does not promise that any insurer, health plan, flexible spending account, health savings account, or other program will reimburse the patient. The patient is responsible for determining eligibility and submitting any permitted documentation.
Good Faith Estimate:
Patients who are uninsured or who do not intend to use insurance for reimbursement are entitled to a Good Faith Estimate when required by federal law. The estimate is not a bill and may change if additional, separately scheduled, or unanticipated services become necessary. Information about the federal patient-provider dispute process is included with the estimate.
Collections:
The practice may use lawful collection methods for unpaid balances. The practice will comply with restrictions applicable during a federal patient-provider dispute process. The patient is responsible for reasonable collection costs only to the extent permitted by the agreement and applicable law.
Acknowledgment:
☐ I have reviewed the fees supplied to me and understand my personal financial responsibility.
☐ I authorize the practice to charge the approved amount through the secure payment method provided by the practice
☐ I understand that payment does not guarantee acceptance, CURT eligibility, a prescription, or a clinical outcome.
☐ I received information about my right to a Good Faith Estimate.
Patient’s printed name:
____________________________________________________________________________
Patient’s signature:
____________________________________________________________________________
Date and time:
____________________________________________________________________________
Parent, guardian, or legally authorized representative, if applicable:
____________________________________________________________________________
Representative’s signature and relationship to patient:
____________________________________________________________________________