By your signature below you are authorizing the above services and you are binding PAYER NAME to reimburse Hospital for the services rendered according to the following terms. If PAYER NAME remits and Hospital receives reimbursement for services rendered within FIFTEEN (15) CALENDAR DAYS from the date of mailing the claim, PAYER NAME is entitled to a ----% discount off of total billed charges.  If PAYER NAME remits and Hospital receives reimbursement for services rendered within THIRTY (30) CALENDAR DAYS from the date of mailing the claim, PAYER NAME is entitled to a ---% discount off of total billed charges.  If PAYER NAME does not reimburse Hospital within thirty (30) calendar days of the mailing of the claim, PAYER NAME receives NO DISCOUNT and must reimburse Hospital at full billed charges. The patient’s UB-04/CMS-1500 will show the actual billed charges.  It will be PAYER NAME responsibility to adjust the payment to reflect the applicable discount based on the terms specified above.

NOTE: Be sure to review my white paper on developing your own Single Case Agreement. There's no obligation to EVER accept a payers' or negotiators' fax agreement on their terms. Take the time to build your own document with this handy checklist.