DELTA PSYCHOLOGICAL & NEUROBEHAVIORAL SERVICES

PATIENT FINANCIAL AGREEMENT

AUTHORIZATION:

In recognition that my health insurance has an applicable mental health benefit, I hereby authorize Delta Psychological & Neurobehavioral Services to bill and collect from my Insurance Carrier directly for any benefit to which I am entitled for services rendered. I also agree to the release of any necessary medical information to the carrier named above or the managed care organization utilized by that carrier to process such claims. Billing for our services is handled by Professional Medical Billing Ltd., Inc. They can be contacted at (989) 791-2455 or (800) 776-6330.

INSURANCE BENEFITS:

The benefits available for mental health services vary from policy to policy and year to year. Your Customer Service contact (see the back of your insurance card) should be able to tell you more about what to expect from this resource. We are on panel with most insurances either as a Clinic or individually. The codes that we use to bill our services are shown below if you discuss this with your representative. Please let us know if we can help in any way as you explore your available insurance benefits.

SERVICES, FEES, and CODES:                          

Initial Assessment (Therapy and Psychiatry)            $260.00         90791  

Therapy Session                                                          $148.00        90834

Half Therapy Session                                                  $100.00          90832

Extended Therapy Session                                        $219.00          90837

Psychiatric Medication Review                                  $148.00          99214

 

Charges and codes for neuropsychological evaluation will be provided at the time of the initial testing consult session.

PLEASE NOTE:

- I understand there is a charge of $35.00 for any returned checks.

- I understand should pursuit from a collection agency become necessary an additional 35% fee will be charged.

- I understand should it become necessary to pursue collection from my insurance company by addressing any problems through the State Insurance Commission, this form provides permission to do so.

- I understand unless cancelled at least 24 hours in advance, there will be a missed appointment fee of $50.00 assessed on my account. This fee will not, and cannot, be billed to an insurance carrier and is my responsibility. If the appointment was for a neuropsychological testing session, the fee for missing the testing without prior notification is $200.00.

- Fees can be paid automatically with your credit card. These arrangements can be made with the office staff.

AGREEMENT:

I am aware of my responsibility to pay my portion of these fees as they are incurred. I understand that if my account is left unpaid by my insurance company the amount becomes my responsibility.

APPLIES TO THOSE WITH TWO OR MORE INSURANCE POLICIES:

I am aware that being insured by more than one company does not mean that my services will always be covered 100%. I am responsible for any balances that remain after all insurance payments have been received.

APPLIES TO THOSE WITH DIVORCE DECREES:

I accept that this office is not a party to my divorce decree. The financial responsibility for accrued fees on behalf of the minor in question rests with myself as I am signing this agreement as the responsible party.

I have read, understand, and agree to accept the financial conditions outlined above.