Due to frequent changes in insurance coverage (benefits, exclusions, deductibles and/or prescription coverage, etc.), we cannot inform or advise you about your benefits. In some insurance policies, certain diagnoses may be excluded, such as ADHD, Autism, Mental Retardation and related conditions. We do not routinely do the paperwork for non-formulary medicines not covered by your insurance company. You are responsible for keeping track of number of visits allowed in your plan and how many visits you have used with your therapist and prescriber. You will be charged for additional visits. If you do not have insurance coverage, you are responsible for the full charges. Please inquire in advance about our charges if you do not have insurance.
It is our policy to collect all co-payments and/or deductibles at the time of service unless arrangements are made ahead of time. We accept checks, cash, and debit or credit cards (Visa, MasterCard American Express or Discover).
A service charge of $10.00 plus interest (1.5%/month) may be added to any outstanding balance over 30 days past due. Also, all delinquent accounts (over 90 days past due) may be turned over to a collection agency. An additional $40.00 as a handling fee and the costs of collection (including attorneys’ fees and costs) will be added to the total amount due.
Cancellation/No Show Policy:
We understand that it is not always possible to keep a scheduled appointment or give 24 hours notice of cancellation. If a pattern of same day cancellation or “No Shows” develop, we reserve the right to bill you $50.00 fee for the missed appointment time. Your insurance company is not responsible for this charge. Prescriptions may not be called in for No Show or Canceled appointments. Additionally, if there are frequent No Show for appointments or non-compliance with treatments, you may be discharged from the practice.
Lost Prescription Fee:
A service fee of $20.00 will be charged to replace lost scripts. Scripts will need to be picked up from the office after payment of the fee.
Fee of $40.00 will be charged for checks returned for any reason.
**Fees may be changed without notice.
I have read and agree to be legally bound by the terms of these office policies including the financial responsibility provisions hereof. I understand that I am financially responsible for any amounts not covered or paid by my insurance carrier and that I am responsible for providing current insurance information and inform the office of any address and/or insurance changes.