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Thank you for choosing Monument, Inc. as your care provider. We are committed to providing quality care and service to all of our patients.

The following is a statement of our financial policy and payment consent, which we require that you read and agree to prior to any treatment.

I (the “patient”) authorize Monument, Inc., and its affiliated medical groups, Live Life Now Health Group, P.A., Live Life Now Health Group of California, P.C., and Live Life Now Health Group of NJ, P.C. (collectively, “Monument”) to securely store a payment method the patient provided to Monument (the “payment method”). The patient authorizes the payment method to be used automatically for any patient responsibilities for payment. If an account is being used for a transaction, Monument may obtain pre-approval for an amount up to the amount of the payment. If the patient wants to designate a different payment method or if there is a change in the patient’s payment method information, the patient must change the information online. This may temporarily delay the ability to make online payments while Monument verifies the new payment information and updates the payment method.

The patient represents and warrants that (i) any payment method information the patient supplies is true, correct and complete, (ii) charges incurred by the patient will be honored by the patient’s credit/debit card company or financial institution, (iii) the patient will pay the charges incurred in the amounts posted, including any applicable taxes, and (iv) the patient is the person in whose name is linked to the payment method and the patient is authorized to make a purchase or other transaction with the relevant payment information.

The patient agrees and authorizes the payment method to be billed automatically for the entire visit, according to the published pricing on the Monument website, which is subject to change at any time. If Monument is unable to secure funds from the patient’s payment method for any reason, including, but not limited to, insufficient funds or insufficient or inaccurate information provided by the patient when submitting electronic payment, Monument may undertake further collection action, including application of fees to the extent permitted by law. The patient also agrees that recurring charges will continue until the patient revokes their authorization as set forth below, and the amount of recurring charges that will be charged to a patient’s account as part of an automatic renewal plan may be subject to change.

  • Fees are payable when services are rendered or at an earlier time agreed upon by patient and Monument. We accept credit cards/debit and pre-approved insurance for which we are a contracted provider, if applicable. Any amounts due that are not paid by pre-approved insurance will be charged to the payment method.
  • Proof of payment is required for all patients.
  • If the payment method on file is declined, we will contact the patient directly to coordinate an alternate method of payment. Please note, if the patient has an outstanding balance on the patient’s account, the patient’s care may be interrupted or terminated. Not applicable to Emergency situations. Monument will provide appropriate referrals to needed care.

I have read the terms contained above, and checking the box below serves as acknowledgement of a clear understanding of my financial responsibility and authorization for Monument to, on a recurring basis, charge my payment method for the amounts due for services rendered. I understand that if my insurance company denies coverage and/or payment for services provided to me, I assume financial responsibility and will pay all such charges in full. Monument is further authorized to debit my payment method for any amount due in connection with services that are not covered by my insurance company or a pre-payment amount agreed to by the Patient that will be reimbursed to the Patient in excess of their copay or coinsurance.

The patient has the right to revoke this authorization by contacting Monument via email at support@joinmonument.com at least fifteen (15) days prior to the scheduled payment date. The patient understands and acknowledges that services may be canceled or withheld if the patient revokes this authorization, and that the patient is still responsible for all charges incurred by the patient or otherwise owed to Monument. This authorization will remain in full force and effect until revoked by the patient or Monument. To the extent permitted by law, the patient acknowledges and agrees he or she will not dispute the payment with the credit / debit card company, provided the transactions correspond to the terms indicated in this authorization form.

Assignment of Benefits & Patient Financial Responsibility Agreement

I hereby assign to Live Life Now Health Group, P.A., Live Life Now Health Group of California, P.C., and Live Life Now Health Group of NJ, P.C. (collectively, “LLN”) all my right, title, and interest in any and all health insurance or other health care benefits payable to me or on my behalf by any insurance payer, including Medicare, private insurance and any other health plan for medical treatment rendered by LLN. This assignment of benefits fully and completely encompasses any and all rights and legal claims I may have under any applicable plan or policy of insurance, the Employee Retirement Income Security Act, or otherwise, to receive benefits. These legal rights and legal claims include, but are not limited to: (i) my rights to make a claim for and/or appeal any denial of benefits on my behalf; (ii) my rights to pursue legal action against the applicable third-party payer for unpaid benefits or for violating any contractual, statutory, legal, or equitable duties to me, including, but not limited to, any and all claims I may have for unpaid benefits, breach of contract, breach of covenant of good faith and fair dealing, breach of fiduciary duty, denial of a full and fair review, quantum meruit, unjust enrichment, or promissory estoppel; and (iv) my rights to file a complaint with any applicable federal or state agency against any third-party responsible for providing benefits.

I hereby appoint LLN as my authorized representative(s) to pursue any claims, penalties, and administrative and/or legal remedies on my behalf for collection against any responsible payer or third party liability carrier of any and all benefits due to me for the payment of charges associated with services provided by LLN. I agree that the insurer or plan’s payment to LLN pursuant to this authorization shall discharge its obligations to the extent of such payment.

The assignment will remain in effect until revoked by me in writing. I authorize the release of pertinent information necessary to process my medical claim. I also authorize direct payment to LLN of all insurance benefits payable to me for such medical treatment. In the event an insurance payer pays me directly, I agree to immediately pay such amounts to LLN.

I understand that my insurance payer may pay less than the actual bill for services. I acknowledge that I am still responsible for paying LLN for any and all amounts not paid by my insurance payer, including non-covered charges and all copayments, coinsurance, and deductibles. I understand I may be asked to pay in advance for services based on my insurance and will be refunded if the amount charged exceeds my co-pay or co-insurance. I understand that if my insurance requires a referral, I am responsible for obtaining one prior to my appointment. In the event any collection action is necessary to collect amounts I owe to LLN, I agree to pay all expenses associated with such action, including but not limited to collection agency fees and attorneys’ fees.

I certify that I have read and understand the foregoing and received a copy thereof. I am the patient, the patient’s legal representative, or am otherwise duly authorized by the patient to sign the above and accept its terms on his/her behalf.

FINANCIAL RESPONSIBILITY AGREEMENT

Live Life Now Health Group, P.A., Live Life Now Health Group of California, P.C., and Live Life Now Health Group of NJ, P.C. (collectively, “LLN”) is committed to providing the best quality medical services (the “Services”). This Financial Responsibility Agreement (“Agreement”) outlines your financial responsibility in relation to receipt of the Services from LLN.

PAYMENT OPTIONS

LLN accepts certain insurance plans, including most Aetna, Cigna, Optum, UHC, Medicare, BlueCross and Anthem plans. Please let LLN know if you have medical insurance that you plan to use for payment of the Services. LLN also offers a self-pay option for the Services. Please see the Self-Payment of Services section below for information on self-pay options. You must authorize payment through agreeing to and signing the Consent for Recurring Credit or Debit Card Payments.

Insurance & Out-of-Pocket Responsibility

Monument accepts a number of insurance plans, including most Aetna, Cigna, Optum, UHC, Medicare, BlueCross, and Anthem plans. If you have eligible insurance coverage, Monument may bill your insurance company directly for services provided.

To keep your costs simple and predictable, Monument uses a prompt-pay discount model for all insured patients. This means:

  • You pay a flat fee at the time of booking, which reflects a prompt-pay discount and covers the full cost of your appointment.
  • This flat fee is your only financial responsibility for the visit — you will not receive additional bills for coinsurance, deductibles, or other insurance-related charges.
  • If Monument is unable to verify your coverage, or if your insurance claim is denied or partially paid, you will still owe only the flat fee paid at booking.
  • If your insurer sends payment directly to you for services rendered by Monument, you agree to remit those funds to Monument immediately.

This policy applies to all insured patients, regardless of the outcome of the insurance claim, and is designed to eliminate surprise billing and streamline your care experience.

OPTION A: Insurance Billing (Prompt-Pay Discount Model)

If you choose to use insurance, Monument will attempt to verify your coverage and submit claims on your behalf. However, under our prompt-pay discount model, you are responsible for paying the flat appointment fee posted at the time of booking, regardless of your plan’s deductible, copay, or coinsurance structure.

This fee:

  • Reflects any applicable prompt-pay discounts.
  • Is due no later than 24 hours before your scheduled appointment.
  • Represents the full extent of your financial responsibility for that visit.

Even if your insurance does not reimburse Monument, denies coverage, or requires additional authorization, you will not be billed anything beyond the flat fee already paid.

If your insurer requires prior authorization or referrals, it is your responsibility to obtain them. However, Monument’s use of the prompt-pay model means that authorization errors will not result in additional charges to you.

OPTION B: SELF-PAYMENT OF SERVICES

Services provided by LLN that are not covered by medical insurance are 100% self-pay by our patients.

  • You are electing to purchase the Services which may or may not be covered by your medical insurance if you obtained similar services from a different provider.
  • You are electing not to use a medical insurance policy benefit.
  • You have been given a choice of the Services provided by LLN, along with their costs.
  • You have selected the Services and you are willing to accept full financial responsibility for payment of the Services.
  • You have selected the Services for purchase from LLN on a self-pay basis. In other words, you have directed LLN to treat your purchase of the Services as if you were an uninsured patient and you therefore agree to be 100% responsible for full payment of the listed price of the Services as set forth in the Fee Schedule below. [Add Fee Schedule or Link to Fee Schedule] Care may be interrupted or terminated based on an outstanding balance (not applicable to Emergency situations, and Monument will provide appropriate referrals to needed care).