Pay with my current health insurance policy. Your insurance policy is a contract between you and the insurance company. It is your responsibility to know your insurance benefits and if Miro Health’s services are covered. We cannot guarantee coverage. Any portion of the service that your insurance does not pay will be billed to you after insurance processes your claim. Pay with my credit card.

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I also understand that copayments or ‘copays’ are due at the time of service through a credit card payment.

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Workers’ Compensation Plans: You are responsible for ensuring that your employer submits the “First Report of Injury” to the proper Industrial Commission. If your insurance company denies the claim because your employer failed to file the notice, the bill will become your responsibility.

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Auto Accident Claims: We will bill your auto policy in the event of an auto accident. If someone else is responsible for the accident, we will NOT bill his or her insurance. You will be responsible for our bill and you will need to seek reimbursement from the other party. I understand that I am financially responsible for all charges regardless of third-party involvement.

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I agree to pay any deductible, co-insurance, copay or any service(s) deemed a “non-covered benefit” by my insurance company.

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I understand that failure to pay outstanding balances within 90 days of receiving my first statement will result in submission of my account to an outside collection agency. If the debt remains after transfer to our outside collection agency, the debt may be reported to credit bureaus and your credit rating may be affected. Failure to pay delinquent account balances may result in termination of care from Miro Health.