With this Payment Policy, Hope Counseling Inc. agrees to:
1. Provide a written receipt for payment at the time of service.
2. Notify you by phone if we have difficulty filing insurance claims on your behalf.
3. Mail written statements to you for any remaining balance on your account.
4. Notify you in writing if a long-standing unpaid bill requires us to utilize a collection service.
5. I agree to pay all reasonable costs you incur to collect this debt. This includes, unless prohibited by law,all reasonable attorney’s fees, filing fees, court costs, collection agency costs, service fees, and other related collection costs or contingencies. I understand that if any unpaid balance is turned over to our collection agency that a fee ranging from 30%-50% will be added to the total balance due. I hereby give you or any of your agents or assignees to whom you turnover any unpaid balance permission to obtain a report from a credit reporting agency and to take reasonable steps to verify my credit and or employment information. I give you or any of your agents or assignees to whom you turnover any unpaid balance to contact me regarding this transaction or any future transaction at any telephone numbers of which they are aware including cellular telephones by manually dialing, using an auto-dialer or pre-recorded message.
If Hope Counseling Inc. takes legal action to recoup unpaid balances, only biographical information and the amount owed will be released to the agency. No mental health information will be released in order to protect confidentiality.
With your payment agreement, your responsibilities are:
1. To make full payments on the date of service when you are meeting the insurance deductible amount.
2. To make your co-payments on the date of service.
3. To sign, understand and comply with terms of the 24-hour cancellation policy.
4. To notify us by phone if insurance checks intended for payment to Hope Counseling Inc. were mailed to you instead. Please mail or bring in the payment and the accompanying Explanation of Benefits form to give to your therapist.
5. To pay your bills within 30 days of receipt, unless other payment arrangements are made in writing with Hope Counseling Inc.
I understand that if my insurance company does not pay for treatment that I will be responsible for payment in full.
If you need to cancel an appointment, please call 24 hours in advance to 217-431-8825. Please leave a message on the appropriate extension for your therapist. The system allows you to leave a message 24 hours a day, 7 days a week.
If you do not call 24 hours in advance to cancel, our policy is to bill $55.00 for the first missed appointment. Second or subsequent missed appointments are billed at $85.00. This amount will be your responsibility since insurance will not pay for missed appointments. Please understand that this policy is necessary to manage our client appointment schedules and to meet our business overhead expenses.
Thank you. We look forward to helping you.
Hope Counseling Inc.