I understand that I am financially responsible for missed appointments, in which I do not give a 24- hour notice and that my credit card will be charged if I do not give the 24 hour notice. The fee for a missed visit (in which less than 24- hour notice is given, including weekends) is $75.00.
In addition, if my insurance company fails to pay for each date of service with in four weeks, I will be billed for the date of service. I will be provided with a super bill so you can be reimbursed by my insurance company. In this process, if payment is received after the four week date of service; I will be reimbursed by NVCC. By signing this agreement I completely understand that it is my responsibility to handle all insurance matters, including getting authorization and untimely payment by my insurance company (more than 4 weeks after date of service I understand that NVCC will file each date of service one time and any rejection payment from my insurance company will be taken care of by me.
I understand that I am financially responsible for all charges not covered or denied by my insurance company. I understand that if I should receive payment from the insurance company by mistake, which payment was/should be assigned to NVCC, I will sign this payment over to NVCC and NVCC has the right to seek legal action to receive payment for this agreement, relative to payment fees, NVCC shall be entitled to reasonable attorney fees and cost of collection.
I further understand that no records (written or verbal) will be released to me or on my behalf if I have an outstanding balance due to NVCC.
NVCC does not accept checks. Please provide us with your credit card information. The card will ONLY be billed for tele-mental health services, if less than 24 hour notice is given, or on accounts that are 60 days past due: