I wish to participate in the Doctors Data, Inc./Labrix Prompt Payment/Professional Price Discount program. I understand that tests will be charged according to the current Prompt Payment/Professional Price Fee Schedule(s), unless otherwise described below, and I agree to comply with the following:
I understand that if I mark the requisition “Bill Practitioner Account” or select “Always Bill Practitioner Account” option below, charges will be billed to my account, and I agree to pay all outstanding balances in full within 30 days of the invoice date. I understand that all accounts are subject to credit review/approval, that credit limits may be established and that unpaid balances over 30 days old are subject to a monthly service charge of 1.5%.
I understand that patient prepayments on Doctor’s Data tests will be charged according to the DDI Prompt Payment Fee Schedule; and that patient prepayments for Labrix tests will be charged according to the Labrix Collect Fee Schedule.
I understand that the Prompt payment/Professional Price/Labrix Collect fee schedules are not available when “Patient billing or Insurance/Medicare billing” is selected and that these tests will be charged according to the List Price fee schedule.
Practitioners in NY, NJ, and RI may not send payments or have charges billed to their account. In these states, financial transactions by the laboratory may only be made directly with patients.
The undersigned agrees to be responsible for payment for tests billed to his or her professional account and to comply with the terms listed above: