At Pure Psychiatry of Michigan, we are committed to providing you with high-quality mental health services. To ensure a smooth and efficient payment process, we have certain financial procedures in place. Please take note of the following information:
We bill usual and customary fees for standard services offered.
Additional services not covered by insurance companies include:
- FMLA, long term medical leave/extensive forms: $50.00
- Short medical leave, short-term leave forms: $25.00
- Late cancel without a 24-hour notice or No-show fee: $50.00
- Returned check fee: $35.00
- Medical record copying will be charged according to State of Michigan rates.
I understand payment for services is due at the time the services are rendered. I understand deductibles and co-pays applicable to my policy is best explained by my insurance provider, but is the responsibility of the patient.
Credit Card Information: Pure Psychiatry of Michigan may require patients to provide credit card information prior to their appointment. This is to ensure that any deductibles determined by your insurance can be covered at the time of your appointment if necessary. Rest assured that your credit card information will be securely stored and processed in compliance with all relevant regulations.
Payment Options: We offer various payment options for your convenience. You have the choice to pay via:
- Credit Card: Your credit card on file will be charged for any applicable deductibles determined by your insurance at the time of your appointment.
- Cash: You may pay in cash if that is your preferred method of payment. Please inform the staff at Pure Psychiatry of Michigan if you intend to pay in cash.
- Check: If you prefer to pay by check, please let our staff know in advance, and arrangements will be made to accept your payment.
- Other Digital Payment Methods: We understand that you may have other digital payment preferences. If you wish to use an alternative digital payment method, please notify the staff at Pure Psychiatry of Michigan in advance so that necessary arrangements can be made.
I understand that Pure Psychiatry of Michigan reserves the right to any outside collection agency as a means of collecting any outstanding balances, if my account remains unpaid or payment arrangements are not made. I understand that if my account goes to collections, I will be charged an additional $50.00.
I understand it is my responsibility to keep scheduled appointments or notify Pure Psychiatry of Michigan staff 24 hours prior to the scheduled appointment time or be charged a $50.00 no show fee. This fee is due at the next scheduled appointment and cannot be billed to your insurance carrier.
Fees are subject to change without notice.
For patients not utilizing insurance, usual and customary fees set forth by Pure Psychiatry of Michigan apply unless a different rate has otherwise been specified. Furthermore, a good-faith estimate is posted on www.purepsychmi.com and is available at each practice for patients use.
By signing below, I acknowledge that I have read, understand, and agree with the financial conditions described above. I understand that Pure Psychiatry of Michigan may require my credit card information and that I have the option to choose my preferred payment method.