RBH PATIENT FINANCIAL RESPONSIBILITY FORM
Thank you for choosing Restore Behavioral Health (RBH) for your behavioral health needs. We are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our patient financial policies.
Patient Financial Responsibilities
• The patient (or patient’s guardian, if a minor) is ultimately responsible for the payment of treatment and care. If your service is a covered benefit under your health plan and if RBH is in network with your health plan, then we will seek any required authorizations from your insurance company and will bill your insurance on your behalf. RBH agrees to accept the contracted rate for services as designated by each insurance plan and does not balance bill. Fee-For-Service rates are collected for any non-covered or out-of-network services. RBH does not file claims to insurance for QEEG or any neurotherapy service; these fees are due at the time of service delivery.
· Prior to service delivery, the patient is required to provide the most correct and updated information regarding primary and secondary health insurance coverage, with timely notification of any changes to health insurance plan. Patients are responsible for filing their own claims for any out-of-network or non-covered services.
• Patients are responsible for payment of co-pays, co-insurance and deductible payments, and fees for all services at the time of service delivery and a credit card is required to be on file for the processing of patient copayments, coinsurance, deductible payments, and account balances. Patients are financially responsible for any services not covered by their health insurance plan for any reason(e.g. beyond the scope of covered benefits, plan considers services not medically necessary, services are beyond plan’s visit limitation, insurance plan does not cover services after providing prior authorization or after indicating that no authorization is required).
· It is the patient’s responsibility to understand the benefits and limitations under his/her health insurance plan. As a courtesy to our patients, RBH will seek initial benefit eligibility and verification information, however it is the patient’s ultimate responsibility to ensure that the benefit information communicated to RBH is accurate, providing updates to RBH with any health plan changes or as insurance deductibles are met. Patients are advised to contact their health insurance plan with any questions regarding the specific benefit information or authorization process for their plan.
• Patients may incur, and are responsible for payment of any additional charges, if applicable. These charges may include:
Ø No Show/ Late Cancellation fees will be applied to any service cancelled with less than 3 business days notice
Ø $45.00 for therapy, test results, neurofeedback, neurotherapy, HBI;
Ø $75.00 for testing and QEEG appointments;
Ø Returned Checks – Insufficient Funds - $30.00 charge
• Patient Statements will be mailed for any outstanding balances. Payments for invoices are due within 30 days of receipt.
By my signature below, I hereby authorize assignment of financial benefits directly to Restore Behavioral Health for services rendered as allowable under standard third party contracts. I understand that I am financially responsible for charges not covered by this assignment.