If you plan to use insurance to pay for services, claims will be sent to the insurance company based on information used at the time of service. Sometimes, insurance information may change or may not be up to date. If for any reason, inaccurate information related to deductibles, co-pays, or number of available sessions, etc. is retrieved at the time of service, KCC will bill the client for any additional costs associated with mental health services rendered. Additional services may not be provided until the client’s balance is current. If balances remain unpaid for 60 days, client information will be sent to a collection agency. I understand that I am responsible for any non-covered services not reimbursable by my insurance carrier.
Self-pay rates may apply to any client who becomes uninsured at times of appointments. Self-pay rates are set for intake and sessions and rates may vary. Please inquire about self-pay rates if you are uninsured during times of services.
MISSED APPOINTMENT FEES
Appointments will be cancelled and $75.00 fee will be assessed if client is 15 minutes late without notice. If client cancels appointment without a notice greater than 24 hours, KCC will charge the client $75.00.
RETURNED CHECK FEE
If your check is returned, your account will be assessed a $35.00 fee.
CREDIT CARD PAYMENTS
You may choose to have KCC store your credit card information for future bills you may incur. Should you do so, KCC will automatically process all outstanding balances one time per month and will not provide any additional warning other than what is written in this section of the Informed Consent form. Please be aware that if your balance is not paid in full after 3 statement cycles your account will be sent to collections with GLA. Please note that once your debt is filed with GLA you will then be liable for an additional charge of 30% of your total balance. We will not permit you to be seen until you have satisfied your outstanding balance in full with GLA.
Credit/Debit Card Policy Terms and Conditions
KCC requires all clients to maintain an active credit/debit card on file at all times. We will ask for this information over the phone at the time of scheduling, and your information will be kept confidential and secure within our electronic medical record system.
By signing below, you authorize Kentucky Counseling Center, LLC to store and charge your credit/debit account for all balances due for services rendered, including late/cancellation fees, and patient responsibilities not covered by insurance that you may incur during treatment. KCC will process all credit cards 1 time per month without further notice if there is an outstanding balance on your account. This typically takes place during the second week of each month.
This authorization will remain in effect until you cancel this authorization in writing or verbally, and you may do so at any time. If you request to cancel this authorization, you are providing KCC permission to use the card on file at the time of your request to pay all outstanding balances before the card is removed. If your payment is declined at the time your card is processed, your services may be subject to termination. My signature indicates that I have read and accept these disclosures.