FINANCIAL RESPONSIBILITY AGREEMENT
At FamilyCare Counseling Solutions, LLC, we are committed to providing high-quality, affordable mental health services. Our goal is to ensure clients have access to care while maintaining transparency about fees, payment expectations, and insurance matters. Please read this agreement carefully. By signing below, you acknowledge and accept your financial responsibilities as outlined.
1. Payment for Services
You are financially responsible for the full cost of all services, regardless of your insurance coverage. Payment is due in full at the time of service, unless a prior agreement is made. We accept:
- Cash
- Check
- Credit/Debit Card (Visa, MasterCard, Discover) – subject to a 3% processing fee
- ACH transfers
We do require a credit card to be on file to authorize payment and your payment will be processed automatically on the day of service. We are happy to provide superbills for clients requesting out-of-network reimbursement.
2. Sliding Fee Scale & Financial Assistance
We offer a Sliding Scale Discount Program based on household income and size. If you're experiencing financial hardship, contact our office to discuss eligibility. Please speak with the Office Manager or Admissions Coordinator for assistance.
3. Insurance Coverage
We may assist with verifying insurance eligibility; however, verification is not a guarantee of payment. Your insurance is a contract between you and your provider. We are not responsible for unpaid or denied claims. You are responsible for:
Copayments (due at time of service)
Deductibles and coinsurance
Services not covered or denied by your insurer
4. Lapsed or Invalid Insurance
You are responsible for charges if your insurance is not active or valid at the time of service. It is your responsibility to inform us immediately of any changes to your insurance.
5. Returned Payments & Late Fees
A $50 fee will apply to all returned checks.
Accounts with unpaid balances after three statements may be referred to collections. You will be responsible for collection costs, including legal fees.
6. Cancellations & No-Shows
Please cancel appointments at least 24 hours in advance.
Late cancellations or no-shows will incur a $50 fee (Two consecutive no-shows may result in discharge)
7. Reimbursement & Third-Party Payments
If you receive direct reimbursement from your insurance by mistake for services we've provided and were supposed to be paid by the insurance provider, those funds must be remitted to FamilyCare Counseling Solutions, LLC immediately.
8. Service Options
You have three options for covering the cost of services:
A. In-Network Insurance Billing
You must provide current insurance information.
We will bill your provider using an appropriate diagnosis code.
You are responsible for any portion not covered, including copays, deductibles, and denials.
B. Out-of-Network Reimbursement
You pay the full cost upfront.
You may request a superbill to submit to your insurance.
A superbill includes required coding for potential reimbursement.
Reimbursement is not guaranteed and is your responsibility to pursue.
C. Self-Pay (Private Pay)
If you choose not to use insurance, you may pay our private pay rates.
Self-pay allows for greater privacy and flexibility, with no insurance-required diagnosis.
9. Insurance Information: To understand your insurance benefits, consider asking your provider:
- Are mental health services covered?
- What is my copay or coinsurance?
- What is my deductible, and has it been met?
- Is pre-authorization required?
- Is there a limit on sessions per year?
10. Acknowledgment and Agreement
By signing below, you:
- Acknowledge you have read and understand the terms of this agreement
- Accept responsibility for any charges not covered by insurance
- Authorize FamilyCare Counseling Solutions, LLC to charge your card on file, if applicable
- Agree to the service fees and financial policies listed above
- Agree to be financially responsible for services received, including copayments, non-covered services, and missed appointment fees.
11. Recovery of Fees/Charges:
- If it becomes necessary for Family Care Counseling Solutions to take legal action to recover the invoiced fees and expenses to which payment has not been made, you are liable for the costs and attorney’s fees incurred by Family Care Counseling to collect any monies owed to it.
Service Option Selection (check below all that apply):
- In-Network Insurance
- Out-of-Network Insurance/Superbill
- Self-Pay