Financial Consent

COST OF INPATIENT ADMISSION

As part of admission to a private inpatient facility, you agree to cover all relevant costs associated with your admission, including, costs related to the facility, as well as, costs associated with regular review with your psychiatrist (Dr Jasveen Kaur). At the conclusion of your inpatient stay and upon your discharge from hospital, an invoice will be issued on behalf of Dr Kaur. This invoice will detail costs associated with medical input and review by Dr Kaur throughout the duration of your admission. This invoice will be submitted to the relevant party (Private Health Fund, Workcover, DVA or Patient/ Guardian etc) for processing and remuneration. 

 You are responsible for all costs associated with your hospital stay and are entitled to request an itemised list of likely costs, as well as, cost of each medical review with Dr Kaur. 

COPAYMENTS ARE DUE AT THE TIME YOU RECEIVE CARE OR SERVICES. THE COPAYMENT AMOUNT IS DETERMINED BY YOUR SPECIFIC INSURANCE FUND. Dr KAUR HAS NO CONTROL OVER THIS COST. YOU ARE RESPONSIBLE FOR ALL OR PART OF THE CHARGES NOT COVERED BY YOUR INSURANCE, BASED ON YOUR COVERAGE AND INSURANCE FUND. AGAIN THESE AMOUNTS ARE NOT DETERMINED BY Dr KAUR, BUT BY YOUR INDIVIDUAL INSURANCE FUND AND LEVEL OF COVER.

NOT EVERY SERVICE IS COVERED BY EVERY INSURANCE PLAN. SOME OR ALL OF THE CARE OR SERVICES YOU RECEIVE MIGHT NOT BE COVERED BY YOUR INSURANCE, OR MAY BE DENIED BY YOUR INSURANCE PLAN. EVEN IF WE HAVE AN ESTABLISHED CONTRACT WITH YOUR INSURANCE CARRIER YOU MAY STILL HAVE SOME FINANCIAL OBLIGATION BASED ON YOUR INDIVIDUAL PLAN. IF THIS IS THE CASE, AND YOUR INSURANCE DENIES PAYMENT, OR HOLDS YOU RESPONSIBLE FOR PART OF THE PAYMENT, YOU WILL BE RESPONSIBLE FOR THE COST DETERMINED BY YOUR INSURANCE POLICY. WE ADVISE THAT YOU ASK YOUR INSURANCE COMPANY TO APPROVE SERVICES IN ADVANCE IF THERE IS ANY QUESTION ABOUT COVERAGE. IF YOU RECEIVE A SERVICE THAT IS NOT COVERED, YOU ARE RESPONSIBLE FOR PAYMENT IN FULL. CASH PRICES ARE $200 FOR INITIAL VISITS AND $125 FOR FOLLOW-UP VISITS.

Upon scheduling your first appointment you will be required to have a debit or credit card placed on file for future charges. This card will be charged the day of your appointment for any copayments due. If your insurance determines you are responsible for additional charges your card will also be charged 7 days after a statement is emailed to you. It is the responsibility of the client to make sure X Company has your correct email address and the client checks the given email address for emailed bills. If you do not agree to the balance on the statement you must call our office at 111-111-1111 to contest the balance within 7 days.  All self-pay appointments must be paid for at time of booking. Members paying through their insurance must email a copy of the front and back of their insurance card to support@xcompany.com within 48 hours from the time the appointment has been scheduled to avoid appointment cancellation.

 I understand my financial responsibility and agree to the above statements.