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.
We accept cash, check, Visa, MasterCard, and Discover.
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
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
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 ______.
INSURANCE CLAIMS: IT IS YOUR RESPONSIBILITY TO KNOW YOUR
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
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.
COLLECTION POLICY-refund policy
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.
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 to an appointment, a $30 fee may be added to your
account at the discretion of the clinician you were to see that
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
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
*****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:_____________