Payment is due at time of service. Please present your insurance cards to the registration desk. If insurance information is not provided, you will default to a self-pay status. Payment, to include co-pays is required prior to a visit. There will be no exceptions to this policy. You will be asked to reschedule your visit if you do not provide the required information and payment/copayment at the time of service. Please complete the Insurance Verification form provided. You will need to contact your insurance company at the mental health phone number they provide on your insurance card. You may use the invoice we provide to you to bill your insurance company if you are self-pay. Sara Weelborg ARNP accepts cash, debit and credit cards, and personal checks. At this time, Sara Weelborg ARNP is contracted with Regence BlueShield and Premera Blue Cross of Washington, Tricare (United Behavioral Military and Veterans), First Choice, Group Health Options PPO, United Healthcare, Medicare, Cigna, and Aetna. Commonly there are several types of health plans under these carriers and it is strongly recommended that the patient contact their plan prior to the visit to inquire about coverage. My signature below indicates that I hereby assume all financial responsibility for services rendered by Sara Weelborg, ARNP. Sara Weelborg, ARNP does not negotiate claims with your insurance carrier. Reduction or rejection of the claim by your insurance carrier does not relieve you of the financial obligation you have incurred for services rendered. Sara Weelborg will accept the contract rate for the insurance plans she is contracted with and will not balance bill. It is your responsibility to determine whether your provider is in your network and to be aware of your current mental health insurance coverage. It is your responsibility to obtain authorization when required by your insurance company. As a new patient, I agree to pay for services at the time of service. Should my insurance be billed, I understand that I am responsible for the copayment at the time services are rendered. Sara Weelborg, ARNP reserves the right to collect deductibles and coinsurance up-front if the account has been delinquent. I agree to notify Sara Weelborg, ARNP when I move or change insurance carriers. I understand that I will be responsible for payment of all charges and will be expected to pay for all costs incurred for collections including court costs, attorney fees and collection agency fees incurred. I authorize Sara Weelborg, ARNP to provide my designated insurance carrier all required information concerning my health information for payment purposes. I authorize benefits for insurance claims to be made directly to Sara Weelborg, ARNP. I understand that certain services to be rendered in the practice may not be covered by my insurance carrier. I am financially responsible to Sara Weelborg ARNP for all charges for services not covered by my insurance carrier. I attest that I have read and understand the above. Questions regarding this policy have been answered to my satisfaction.