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.
Your signature on this form authorizes PBS Mental Health Associates, PC, (PBS) to release to your insurance company information for billing purposes and direct payment to PBS. It also authorizes us 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.
CO-PAYS
Your co-pay is due at the time of service. If not paid, a non-refundable $5.00 billing fee will be added to your account for that date of service.
NON-PARTICIPATING INSURANCE CLAIMS
If we do not participate with your insurance company, we will collect payment in full at time of service. We will provide you with a receipt for you to turn in to your insurance company for reimbursement. This also applies to Major Medical Claims.
MEDICAL ASSISTANCE Circle here if N/A
We do not participate with this insurance and cannot and will not bill them. ALSO, you are responsible for any balance over your primary insurance. Initial here:________
FILING YOUR INSURANCE CLAIMS
If your insurance company denies any claim because they need information from you, it is your responsibility to contact them and have them reprocess these claims. If your insurance company leaves any balance unpaid, it is your responsibility to contact them to dispute these balances. To avoid billing errors it is your responsibility to notify us of any INSURANCE CHANGES before your next visit.
MISSED APPOINTMENTS/LATE CANCELLATIONS
We require 24 hours' notice for cancellation of an appointment. If you do not call within this time frame OR no show for an appointment, a $30.00 charge will be added to your account. This fee is at the discretion of the clinician you were to see that day.
MEDICARE PARTICIPANTS
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 Heatlh Care Administration and its agents any information needed to determine these benefits or the benefits payable for releated services.
SIGNATURE:___________________________________________ DATE:__________________
I have read and understand the above financial policy.
Patient name:___________________________________________ MRN#________________
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