Payment for services provided by Dana Group Associates is due at the time of services rendered unless payment by health insurance has been arranged prior to the visit. If insurance coverage has been arranged, payment of any applicable copayment or deductible is due at the time services are rendered. If we do not have a contractual provider relationship with your insurance plan, full payment for services is due at the time services are provided. We will bill your insurance for you, and reimburse you if we receive payment. You agree to be fully responsible for payment of all services not covered by your insurance. If there is a problem with your insurance coverage, you agree to pay your bill and handle any issues with your insurance company yourself. As a courtesy to you, we will attempt to verify your insurance coverage and determine your insurance benefits. However, if your insurance company has misinformed us or you feel we have misinformed or failed to adequately inform you regarding your benefits, you are still responsible for payment of all charges not covered by your insurance. We encourage you to verify your insurance benefits and coverage yourself and make sure that you fully understand your coverage. By signing this agreement you agree to be responsible for all charges for the client identified below, even if you believe another party should bear responsibility for these charges. Some services may not be covered by health insurance. You agree to be fully responsible for all services that are not covered by the health insurance plan. This may include charges for telephone consultation, written correspondence, or reports in connection with a client’s evaluation or treatment, including consultation or correspondence with the client, family members, past or current treatment providers, educational professionals, attorneys, courts, agencies, or others. Limited telephone consultation is part of routine patient care and is undertaken without charge. However, when extensive telephone consultation or other than routine written correspondence or reports are requested or required, a charge for these services will be applied. If these charges are excluded from coverage by health insurance plan, they will be your responsibility. Every effort will be made to notify you if such charge is likely to occur. However, the exact amount charged cannot always be predicted in advance.
When an appointment is canceled without at least 48 hour prior notification, a $50 fee for the canceled appointment will be charged. If an appointment is missed, considered as a No-Show, a $100 fee for the no-show appointment will be charged. Fees charged for missed appointments or late cancellations must be paid prior to the next appointment. A service charge of 1.5% of the outstanding balance or a minimum of $5 will be added each 30 day billing cycle to all outstanding balances over 60 days past due. A charge of $25.00 will be applied for all checks returned unpaid. If an overdue account is sent to a collection agency, collection fees and expenses will be added to the amount due. A copy of the current applicable fee schedule of Dana Group Associates is available upon request. Fees may be modified without notice.
- Acknowledgement and Agreement
I have read the above and affirm that everything in this form that was not clear to me has been explained to my satisfaction. I understand that it is my responsibility to know my insurance benefits. I hereby agree to abide by the policies specified above and to be responsible for all fees and charges for services provided by Dana Group Associates to or on behalf of the client named below. This agreement will continue as long as Dana Group Associates provides services or until written request that this agreement be terminated is received by Dana Group Associates.
- Assignment of Health Insurance Benefits:
This signature below authorizes payment directly to Dana Group Associates of benefits under health insurance policy covering the client named below. A photocopy of this form is considered as valid as the original. For Medicare Clients only: The undersigned hereby requests that payment of authorized benefits be made to Dana Group Associates on behalf of the client named below. The undersigned authorizes any holder of medical information about the client to release the Health Care Financing Administration and its agents any information needed to determine those benefits payable for related services.