Cancellation and Overdue Billing
Please provide at least 24 hour for cancellation to avoid a late cancellation/missed appointment fee. A missed appointment fee of $50 will be charged to the credit card on file. Reschedule missed appointments within one week of original appointment to avoid this fee.
Billed charges that are unpaid by insurance after 60 days will be charged to the credit card on file. You will be refunded for any overpayment once insurance payments are received.
Certification and Authorization
I certify that the above information is correct. I authorize the release of any medical information necessary to process this claim. I request that payments be made directly to Karin Elise Weber, LCSW, PLLC on my behalf. Therefore my signature will be on file to file with my insurance company.