Terms of service

The Patient hereby certifies that the information given to Pulsed Energy Technologies, LLC. in applying for equipment/accessory purchase is true and correct, and authorizes Pulsed Energy Technologies or its designee to bill any third party payors and request that payment of authorized benefits be made to Pulsed Energy Technologies or its designee on the Patient’s behalf.

Patient authorizes Pulsed Energy Technologies to file an appeal as required due to their health insurance plan’s initial or subsequent claims denial and/or benefit determination. Patient fully understands that, in the event that his/her insurance plan does not pay Pulsed Energy Technologies in full, s/he will be financially responsible for all unpaid balances, including applicable sales tax, co-payments and deductibles, less any deposit paid, and will pay such amounts within thirty (30) days of notice from Pulsed Energy Technologies.

If litigation is instituted to collect any unpaid balance, Patient agrees to pay all costs of collection, including reasonable attorney’s fees, incurred by Pulsed Energy Technologies.

AUTHORIZATION AND RELEASE OF MEDICAL INFORMATION

You hereby authorize Pulsed Energy Technologies, LLC. and/or any related parties associated with this transaction to release to third party payers, insurance companies, health insurance insurers, or medical necessity/utilization review organizations, any information needed to determine payment of authorized benefits until all outstanding charges for you associated with Pulsed Energy Technologies equipment/accessories have been paid.

You further agree that Pulsed Energy Technologies, its employees, agents, representatives, Business Associates, and accrediting and governmental agencies may access, request, and receive from healthcare providers involved in your care, and use or disclose your medical information for the purposes of providing Pulsed Energy Technologies equipment/accessories, obtaining/substantiating payment for equipment/accessories, and administering related business operations, in accordance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, as amended.

PATIENT ACKNOWLEDGEMENT

This agreement consists of all of the terms and conditions on this page and the reverse side whether written or printed. I certify that I have read the terms and conditions of this agreement and agree to be bound by such provisions. I accept full responsibility for all services rendered, including being informed of my rights, responsibilities, and complaint procedure.

PROFESSIONAL SPORTS TEAM, COLLEGE OR UNIVERSITY

I understand that Pulsed Energy Technologies has agreed to bill the patient’s insurance carrier as a courtesy to the patient and our organization. Unpaid claims within 120 days of submission to the primary carrier will immediately become the responsibility of my organization.

Pulsed Energy Technologies shall not be required to appeal negative coverage decisions on behalf of the patient and/or the organization. I understand and agree that in the event that the patient’s insurance carrier does not pay Pulsed Energy Technologies in full the retail rate of the system and supplies provided, including applicable taxes and freight charges, that the organization will be fully responsible for 100% of all unpaid balances and will pay such amounts within thirty (30) days of notice from Pulsed Energy Technologies.

I acknowledge that any contractual discounts or allowances taken on behalf of a third party administrator, bill-review organization, or managed care organization (MCO) shall not apply to this transaction and that the original billed amount is the full balance and shall be due and payable; less any monies paid by the patient’s primary and/or secondary insurance.

I further acknowledge that I am duly authorized to enter into this financial agreement on behalf of my organization.

LATE PAYMENT

If payment is not received by the due date, Buyer agrees to pay a one-time late fee of three percent (3%) of the overdue amount. In addition, any unpaid balance shall accrue interest at the rate of one and one-half percent (1.5%) per month until paid in full.

TAXES

Buyer shall be responsible for and pay all taxes arising out of the sale, delivery and transfer of the Products. Seller shall state on all invoices any sales, use or similar taxes imposed by federal or state government applicable to furnishing of the Products.

GOVERNING LAW

This Agreement shall be construed and interpreted pursuant to the laws of the State of California without consideration to its choice of law provisions. The parties consent to the jurisdiction of the location of the court as set forth hereinafter, and hereby waive all objections to such jurisdiction and venue. All claims shall be brought in Los Angeles, California.