Financial Consent

COPAYMENTS ARE DUE AT THE TIME YOU RECEIVE CARE OR SERVICES. THE COPAYMENT AMOUNT IS DETERMINED BY YOUR SPECIFIC INSURANCE PLAN. X COMPANY HAS NO CONTROL OVER THIS COST. IF YOU WILL NOT BE ABLE TO PAY THE COPAYMENT AT THE TIME YOU RECEIVE CARE OR SERVICES, YOU WILL NEED TO CALL AHEAD TO SEE IF YOU WILL BE ABLE TO KEEP YOUR APPOINTMENT. YOU AS THE CLIENT ARE RESPONSIBLE FOR ALL OR PART OF THE CHARGES NOT COVERED BY YOUR INSURANCE, BASED ON YOUR COVERAGE AND INSURANCE PLAN. AGAIN THESE AMOUNTS ARE NOT DETERMINED BY X COMPANY BUT BY YOUR INDIVIDUAL INSURANCE PLAN.

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.

Appointments cancelled at least 24 hours in advance of the appointment time will receive a full refund. Unfortunately due to our commitment to respecting the time of both our other patients and our providers, any appointment cancelled or not attended with less than a 24 hour notice is subject to a 50% cash fee (totaling $100 for initial consultations and $62.50 for follow ups), which must be paid before scheduling a new booking. In the case of virtual visits patients are responsible to have the app downloaded correctly and be in an area that has sufficient Internet coverage or cell coverage to allow for the visit. If the patient does not have the app downloaded correctly or does not have sufficient Internet or cell coverage to complete the visit this will be considered a missed appointment and the patient will be required to pay a no-show fee to rebook subsequent appointments. We strongly encourage all patients to test the app prior to their appointment time to avoid any technical difficulties that may result in a no show and subsequent fees.

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