DISCLAIMER: Please be aware, a quote of benefits IS NOT AN AUTHORIZATION FOR TREATMENT. Itis simply a projected out of pocket cost from your Insurance for this specific service. INSURANCE LIABILITY: By signing this form, you acknowledge that your Insurance coverage, notification of any preauthorization requirements, and terms of coverage are ultimately your responsibility. We make every attempt to verify your benefits, obtain pre-authorization and will communicate this to you, SO that you know if your health Insurance company determines that a particular service is not reasonable and necessary or not covered under the plan. Statements and financial responsibility will default to you after the claims have been processed. You can follow up with our billing department for payments. In the event that services are provided and your coverage is not in effect on that day, your deductible has not been met yet, or if authorization has not been requested prior to service. The charges will then become your responsibility payment and will be due at time of service. Please understand that when we schedule your appointment, we are reserving time for your particular needs. We kindly ask that if you must change or cancel an appointment, please notify us no less than 24 hrs in advance or you may Incur a fee.
AGREEMENT: By signing this document, you agree to the following statements: Iacknowledge it is my financial responsibility for any amount not covered by my health Insurance plan. Iagree and consent to participate in treatment and understand that a positive outcome cannot be guaranteed. I understand that positive outcomes are based on my compliance with treatments. I also understand that there are some Instances where TMS therapy in certain circumstances, may not provide symptom relief even if I attend every session, and participation does not guarantee that my symptoms or concerns will be resolved.