MINDDEVELOPERS COUNSELING & SUPERVERVISION PC FINANCIAL AGREEMENT AND PROMISE TO PAY ACCOUNT

For in and consideration of services rendered and to be rendered to will promise to pay MindDevelopers Counseling & Supervision PC  (MindDevelopers I understand the total charges are due when services are rendered. I agree to make available any and all insurance information to MindDevelopers Counseling & Supervision PC and/or billing personnel. I understand that MindDevelopers Counseling & Supervision PC bills from One hundred and twenty five dollars to one hundred and eigthy-five dollars ($125-$185) for sessions lasting 45-60 minutes, based upon therapist and their licensure. I agree to provide insurance claim forms of any insurance company and/or will complete the HCFA 1500 form. I agree to assign any and all benefits to MindDevelopers Counseling & Supervision PC and sign in the designated areas on the insurance claim form. I agree to pay the entire deductible amount, as well as any co-payment amount due. I understand that I am financially responsible for missed appointments ($75 per occurrence), in which I do not give a 24- hour notice and that my credit card will be charged if I do not give the 24 hour notice. The fee for a missed visit (in which less than 24- hour notice is given, including weekends) is $75.00. In addition, if my insurance company fails to pay for each date of service with in four weeks, I will be billed for the date of service. I will be provided with a super bill so you can be reimbursed by my insurance company. In this process, if payment is received after the four week date of service; I will be reimbursed by MindDevelopers Counseling & Supervision PC. By signing this agreement I completely understand that it is my responsibility to handle all insurance matters, including getting authorization and untimely payment by my insurance company (more than 4 weeks after date of service I understand that MindDevelopers Counseling & Supervision PC will file each date of service one time and any rejection payment from my insurance company will be taken care of by me. I understand that I am financially responsible for all charges not covered or denied by my insurance company. I understand that if I should receive payment from the insurance company by mistake, which payment was/should be assigned to MindDevelopers Counseling & Supervision PC, I will sign this payment over to MindDevelopers Counseling & Supervision PC and MindDevelopers Counseling & Supervision PC has the right to seek legal action to receive payment for this agreement, relative to payment fees, MindDevelopers Counseling & Supervision PC shall be entitled to reasonable attorney fees and cost of collection.

I further understand that no records (written or verbal) will be released to me or on my behalf if I have an outstanding balance due to MindDevelopers Counsleing & Supervision PC. MindDevelopers Counseling & Supervision PC does not accept checks. Please provide us with your credit card information. When applicable, your card may be charged the day prior to your scheduled appointment or after services are rendered once the patient responsibility is determined.

 

An active credit or debit card must be kept on file in order to start and maintain services.Your card may be charged for the following: Session fees or patient responsibility balances , missed appointment or late cancellation fees, lapses in insurance coverage, documentation requests, court appearances, stakeholder consultations, and/or other approved service-related charges. When applicable, your card may be charged the day prior to your scheduled appointment or after services are rendered once the patient responsibility is determined.If your account balance exceeds $75, future appointments may be cancelled until the balance is paid. If two consecutive appointments are missed within a 90 day period and missed visit fees are not paid, your case may be discharged and any outstanding balance may be sent to collections with a 15% late fee per invoice applied to the unpaid balance. By signing this agreement, you authorize the practice to charge the card on file for any patient responsibility balances.

promise to pay MindDevelopers Counseling & Supervision PC (MindDevelopers Counseling & Supervision PC I understand that MindDevelopers Counseling & Supervision PC bills at the rate of $200.00 per hour for court attendance. I agree to provide MindDevelopers Counseling & Supervision PC with my credit card information. I understand that the hourly rate begins when the therapist leaves their location. I understand that a fee for two hours will be paid prior to court attendance, ($400.00) and is non-refundable if less time is needed. If the court attendance exceeds two hours, I understand that my credit card will be billed for the remaining time. In addition, I understand that I am not paying for the therapist's testimony; I am paying for their time. Therefore, the fees are expected to be paid regardless of whether the therapist testifies or not.

 

On call policy:

I understand that if I request my therapist to be on-call for court attendance, MindDevelopers Counseling & Supervision PC  bills at the rate of $75.00 per hour for on-call. I agree to provide MindDevelopers Counseling & Supervision PC with my credit card information in order for the payment to be charged. I understand that the hours I am requesting the therapist to be on call will immediately be charged to my credit card, and is non-refundable.

Communication with Attorneys/Other professionals/Report writing:

I understand that MindDevelopers Counseling & Supervision PC bills at the rate of $125.00 per hour for any type of communication with attorneys/other professionals/report writing (phone calls, letter writing, email, consultation, etc I understand that I will need to provide my credit card information prior to any communication my therapist will have with my attorney/outside professional. I understand that a minimum of 30 minute increments will be billed to my credit card and is non-refundable.

Records Request

For each separate request, MindDevelopers Counseling & Supervision PC bills a flat rate of $25 for records to be copied and faxed/given to the client. If records need to be mailed, an additional fee of $10 is assessed to cover certified mail and postage. After payment is received and processed, please allow up to 7 business days for copies to be provided and/or mailed. I also understand that no disability paperwork, work leave of absence, FMLA, etc will be completed before the third (3rd) session.

MindDevelopers Counseling & Supervision PC does not accept checks. Please Provide Credit Card Information:

An active credit or debit card must be kept on file in order to start and maintain services.Your card may be charged for the following: Session fees or patient responsibility balances , missed appointment or late cancellation fees, lapses in insurance coverage, documentation requests, court appearances, stakeholder consultations, and/or other approved service-related charges. When applicable, your card may be charged the day prior to your scheduled appointment or after services are rendered once the patient responsibility is determined.If your account balance exceeds $75, future appointments may be cancelled until the balance is paid. If two consecutive appointments are missed within a 90 day period and missed visit fees are not paid, your case may be discharged and any outstanding balance may be sent to collections with a 15% late fee per invoice applied to the unpaid balance. By signing this agreement, you authorize the practice to charge the card on file for any patient responsibility balances.