(effective January 16, 2017)

You must review and sign this form prior to your first session.  You may do so in the waiting room before the session but are encouraged to complete the form prior to your arrival in the office.  You may print this form by clicking here.

***PAYMENT***   We accept cash, check, Visa, MasterCard, and Discover.
Your co-payment, deductible, and co-insurance amounts are due at the time of service and are a part of the contract between you and your insurance company.  They cannot be written off or discounted for any reason by our office.

Payment in full is due at time of service, unless a payment arrangement has been approved by our staff prior to your appointment date.

There will be a $25 fee for all returned checks. This fee and the amount of the returned check must be paid by cash or credit card.  Multiple check returns will result in your being required to pay in cash or credit payment only and may be subject to filing with the local magistrate.

We DO NOT participate in this insurance and are not taking new patients that have this insurance.  However, if you have Value Behavioral Health AND are an established patient, you are able to self pay (out of pocket) for services here.  By initialing here you agree to self pay for services at our office and not to utilize your in-network benefit with your insurance company.  Initials: ______  Initial here if you DO NOT have any form of Medical Assistance ______.


Please remember that your insurance policy is a contract between you and your insurance company.  We will as a courtesy bill your insurance company to help you receive the maximum allowable benefit under your policy.  Any unpaid balances are your responsibility.  If we are not in-network with your insurance company, payment will be due in full at the time of service, and an itemized receipt will be given to you for self-reimbursement.

A $25 fee is billed for any forms or letters completed on your behalf and sent to other providers, attorneys, employers, and/or insurance companies.  This fee is due prior to information being sent.

Our office attempts to collect any outstanding balance using monthly statements AND by asking for payment upon check-in.  Payment on your account is due immediately upon receipt of statement.  If you are experiencing financial difficulty, please notify our billing department.  A 3-, 6-, 9-, or 12-month payment plan is available, depending on your account balance.  Our office will make every possible attempt to collect on your account prior to taking outside collection agency action.  If your account is sent to collections, your FULL AMOUNT DUE will need to be paid IN FULL before you will be able to reschedule with anyone in our practice.  No refund under $1.00 will be issued by us or will be expected to be made to us.

We require 24 hours’ notice for cancellation of an appointment.  If you do not call within this time frame OR no show to an appointment, a $30 fee may be added to your account at the discretion of the clinician you were to see that day.

In the event of an emergency closing, all phones will have a pre-recorded message with instructions.  You will be contacted by a staff member within 24 hours regarding the closure and/or rescheduling.  If you are in need of immediate assistance, please report to the nearest emergency room.

We need two days’ notice to process medication refills.  If it has been more than six months since you were last seen in the office, you will be asked to schedule an appointment before a refill can be authorized.  NO REFILL REQUESTS CAN BE COMPLETED AFTER NOON ON FRIDAYS!

I request payment of authorized Medicare benefits to be made on my behalf to PBS for any services furnished to me.  I authorize any holder of medical information about me to release to the Health Care Administration and its agents any information needed to determine these benefits or the benefits payable for related services.

*****Your signature on this form authorizes PBS Mental Health Associates, PC, (PBS) to release to your insurance company information for billing purposes and to direct payment to PBS.  It also authorizes PBS to release information concerning medical care related to mental health, medications, treatment planning, and information related to utilization and quality assurance reviews to your insurance company should they require it.  You also agree to endorse over to PBS any checks paid to you by your insurance company that were for services rendered in our office.  It is insurance fraud to cash these checks and not turn the monies over to us.  My signature below acknowledges I have read all policies above and agree to all terms.

Patient name (printed)_________________________________________________________

SIGNATURE (patient or parent of minor):__________________________________________  DATE:_____________