PLEASE NOTE: To complete a paper verions
of this form, please click here
NOTICE OF PRIVACY PRACTICES
FCA's “Notice of Privacy Practices” was available review below, and is also available at at www.fca-NE.com. I am aware that I can also ask my clinician for a paper copy. I understand that I may ask questions about the information outlined in the Notice at any time in the future.
I give permission to FCA to contact me at the phone number(s) or email listed on this Client Registration Form. If I am not available, I authorize Family Counseling Associates to leave a message on my voicemail. My signature below indicates that I am aware that the “Electronic Communication Policy” is available for my review at www.fca-NE.com. I am aware that I can ask my clinician for a paper copy.
Family Counseling Associates has recently partnered with Refresh Billing. Refresh Billing is a mental health billing organization located in Sarasota Florida. We have been in business since 2000. Our goal is to provide Family Counseling Associates’ patients support with all billing and insurance claims related matters. We have a team of certified medical coders and billers with over 100 years of combined experience.
Refresh Billing is passionate about what we do, and we hope to be a support to Family Counseling Associates’ clients!
What does this mean for you? We are here to help!
You will notice a few changes in the near future as we work to get account statements and billing information out to you in a timely manner. You may receive statements from us by mail or by the email you have provided. Please follow the secured link, create a login, view your detailed statement, and call the phone number below to make your payments. We may be contacting you by phone regarding balances or insurance questions.
Coming soon, you will be able to access a portal where all of your current billing information and forms will be located. You will be able to log on and view your information or pay an outstanding balance. This will help to make our communication efforts quick and easy for you and your provider. We will send out another letter to you before this goes into effect. We aim to provide compassionate, patient-centered care for all.
We are looking forward to working with you!
Please do not hesitate to contact us with any inquiries or billing questions at: (877) 299-5426 Option #4.
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