FINANCIAL RESPONSIBILITY AGREEMENT

Meru Health Medical, P.A. and its affiliated medical groups (collectively, “Meru Health”) are committed to providing the best quality healthcare services (“Services”).  This Financial Responsibility Agreement (“Agreement”) outlines your financial responsibility in relation to receipt of the Services from Meru Health.

Meru Health accepts certain insurance plans in certain states. Please let Meru Health know if you have medical insurance that you plan to use for payment of the Services. Please note that Meru Health only accepts your primary insurance and does not assist in the submission of medical insurance claims to any secondary insurer.  

As a courtesy to its patients, Meru Health is pleased to assist in the submission of medical insurance claims to insurance companies for payment. Currently, Meru Health participates with and solely bills commercial health plans. Meru Health does not participate with any federal health care providers or any health plan not identified herein.

To the extent you have insurance, by signing below, you understand and acknowledge that:

Your medical insurance policy, if any, is a contract between you and your insurance company. The actual charge(s) for Services could exceed the amount of any estimate provided by Meru Health. It is your responsibility to know your benefits, how they will apply to payment for the Services, and paying any amounts that are identified as being your responsibility by your insurance company.

It is your responsibility to confirm that the provider that you see at Meru Health is a participating provider under your medical insurance policy.

Your insurance company may not cover 100% of the costs and fees associated with the Services, and you will be responsible for payment of any remaining balance due for the Services, including without limitation, for paying co-payments, deductibles, and any other costs and fees associated with the Services you receive that are not fully (or at all) covered by your insurance company.

It is your responsibility to provide Meru Health with appropriate and current medical insurance information, and to notify Meru Health immediately upon any change in your medical insurance coverage to ensure efficient claims billing and payment. In the event that you fail to provide all necessary and current medical insurance information, you understand that your insurance company may deny payment of claims relating to the Services, and you understand that you are 100% responsible for any costs and fees associated with the Services that are not covered by your insurance company.

It is your responsibility to have obtained any and all necessary referrals and authorizations required prior to receiving the Services from Meru Health. If your insurance company requires a referral and you do not have one, then you understand that you will be responsible for all the costs and fees associated with the Services you receive.

If your medical insurance requires a co-pay or deductible or co-insurance amount, you are responsible for paying any patient owed payments to Meru Health as determined by your insurance company. 

To the extent you have insurance, with acceptance of this agreement, you further hereby authorize payment of all medical insurance benefits which are payable to you under the terms of your medical insurance policy to be paid directly to Meru Health for the Services rendered.

How to Contact Us:

If you have any questions, feedback you may email us at [email protected] or contact us by mail addressed to:

Meru Health, Inc. | 720 S B St | San Mateo, CA 94401 | Telephone: (650)-505-494