Payment / No show fee / Non Covered Services CONSENTS
Payment of services:
Our policy requires that you pay at the time services are rendered. With proper insurance filing information given by you to us, We will file an insurance claim to your carrier as a curtesy to you but our agreement is with you not the insurance carrier. This means although we will submit the claim, you are ultimately responsible for your treatment. We accept any credit card payments, cash or check.
Co - payments and deductibles are due upon receipt of services.
You are liable for the "No call, No show" fee of $175 charged to your account if you miss your appointment without a 24hr notice to the office.
Non - covered services:
You are responsible for any services identified by your insurance carrier as non covered services if you & / or your physician requests these services & you agree to it.
INFORMED CONSENT FOR NON COVERED SERVICES
I, the undersigned, am requesting this treatment, from a Grace Point Behavioral provider. I have been informed that my insurance carrier does not cover this service & or this provider. I elect to receive this service & agree to provide payment for this service & or provider as these services are rendered.
INSURANCE “USUAL & CUSTOMARY FEES”
Grace point Behavioral has a set fee schedule for services. Your insurance carrier may determine that a physicians’s fees are above the ”usual & customary” amount (UCA). IN OTHER WORDS, THE FEE THE INSURANCE COMPANY IS WILLING TO PAY (the allowable amount) IS LESS THAN THE PHYSICIAN’S SET FEES. In most cases, it is still your responsibility to pay the difference between the physician’s fees and the allowable amount.
STATEMENT TO PERMIT A PAYMENT OF MEDICAL BENEFITS TO PROVIDER, PHYSICIAN & PATIENT by medicare :
I certify that the information given by me in applying for payment under title XVII of the social security act is correct. I authorize any holder of medical or other information about me, to release to the social security administration or its intermediaries or carriers, any information needed for this or a related medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the service or authorize such physician or organization to submit a claim to medicare for payment.
My signature here signifies that I have read and understand each of the above consents and that I give my knowing and informed consent for the items initialed above.
Signature of patient: Date:
Signature of legal guardian / parent: Date:
Signature of witness: Date: