Thank you for choosing Pattison Professional Counseling Center. We are committed to your successful treatment. The following is our financial policy, which we request you read, understand, and sign prior to treatment.
Insurance: Your insurance policy is between you and your insurance company. We are not a party to that contract. If services are not covered by your insurance policy, you are responsible for all session fees. We do accept assignment of benefits from insurance companies with which we are participating providers. All Tricare/Champus clients must obtain a doctor’s referral in order to file the insurance claims. If the client does not obtain a referral and insurance cannot be filed, the client is responsible for the entire session charge. We will file your insurance claims for you, either by paper claim or electronically, unless otherwise specified by you.
Assignment of Benefits: I assign my insurance benefits to Pattison Professional Counseling Center for the duration of my treatment.
Payments: All payments, co-payments or deductibles are due after each session. If your co-payment is not known on the first date of service, a co-payment of $20.00 will be collected at the time of each session until your correct co-payment can be determined. We accept cash, checks, money orders, Visa, MasterCard, and American Express for payments. We can also keep your credit card number on file and charge your card with your cost share after each visit.
Missed or Cancelled Appointments: 24-hour notification is required if you need to cancel or reschedule your appointment. A minimum of $30.00 will be charged to your account if you do not show for your scheduled appointment or give us 24-hour notification. For psychiatric patients, a minimum of $50.00 will be charged. If calling to cancel or reschedule your appointment after business hours, please leave your name, appointment date and time, and a brief message on our voice mail. We appreciate your assistance in helping us serve you better by keeping scheduled appointments.
Billing: Payment for all client statements is due in full upon receipt. A divorce decree cannot assign responsibility for an adult or child’s account. Failure to pay your bill could result in your account being turned over to a collection agency. Only your name and account status will be discussed with the collection agency.
Returned Checks: A $30.00 service fee will be added to your account for each returned check from your bank. Only cash payments will be accepted if two NSF checks are received.
My signature acknowledges that I have read, understand, and agree to all parts of the financial policy of Pattison Professional Counseling and Mediation Center (PPCC Inc). I also understand that my account will be turned over to a collection agency if it becomes delinquent.