By my signiture below, and my presence at TCFP, I hereby authorize TCFP to provide mental health care. I authorize The Center for Psychology to release to my insurance company, managed care organizations, state agency/agencies, Health Care Financing Administration, Third Party Administration, and/or Workers' Compensation or its agents any information needed to process my claims and/or determine benefits payable for related services.

If I am entitled to mental health benefits arising out of any insurance policy or from any person or organization who is or may become liable to me to provide such benefits, I hereby assign and authorize payment of such benefits for mental health services to which I am entitled to The Center for Psychology for services rendered to me. 

If applicable, I request that payment of Medicare benefits for mental health services be made on my behalf and assign them to The Center for Psychology and authorize submission of the necessary claims for payment. I authorize any holder of medical, mental health, and/or any financial information about me to release to the Health Care Finacing Administration, or Medicare intermediaries, or Medicare Carries any information needed for proper reimbursement. 

I understand that The Center for Psychology participates and/or has contracted agreements with selected insurance plans/third party payers. I understand that unless otherwise restriced by a contractual agreement with such plans/third party payers, the entirety of the charges incurred that I agree to will be transferred to the guarantor's responsibility as per the EOB or if the payment is not recieved from insurance within 60 days. I understand that I will be bound by any conditions of this agreement regarding guarantor/patient responsible charges. I understand that failure to meet my financial responsibilities in a timely manner may result in my account being turned over to a collection agency. I understand that I am responsible for any collection fees, attorneys' fees, and/or court fees that may be involved.

I agree to maintain a current credit card on file at TCFP and that my credit card can be charged for any outstanding balance as per my insurance EOB for deductible and/or copay or coinsurance and/or missed appointment fee. 

I understand that I must provide The Center for Psychology no less than 2 business days notice to cancel an appointment. Example:if your appointment is Monday cancellations must take place Thursday to avoid a $100 fee. Same day appointment cancellations are subject to a charge that shall be billed directly to me, and payment of any missed appointment charge will be my sole responsibility. 

I understand that all patient responsible charges are due at the time of service.

I agree to the above conditions.