I agree to pay in full, at the time of service, for all services rendered on my behalf by Beacon Psychology. I understand that Beacon Psychology will provide me with a billing statement that I can file with my insurance provider for reimbursement if I choose not to use my insurance benefits or if Beacon Psychology is not a participating provider with my insurance plan. I understand that if Beacon Psychology is a participating provider with my insurance company that I will pay the full co-pay at time of service and that Beacon Psychology will submit a claim to my insurance provider. I understand that if my child has Medicaid, Medicare, or Tricare coverage, services provided at this office are non-Medicaid, Medicare, or Tricare reimbursable, and that I assume full financial responsibility for all services rendered.
I agree to provide accurate and updated healthcare/insurance information to Beacon Psychology to assist in financial reimbursement from healthcare insurance for services provided. I hereby give consent to Beacon Psychology to release any required information to my healthcare insurance to assist in the processing of claims, including protected healthcare information in accordance with the Health Insurance Portability and Accountability Act (HIPAA I acknowledge and understand that I am responsible for all charges not paid by insurance benefits, in accordance with applicable laws and regulations.
Iunderstand that 24 hours notice of cancellation is required to avoid charges for missed appointments. I am aware that I may be charged a late fee if I arrive more than 15 minutes late for my appointment, and that late charges as well as missed appointments are not covered by insurance plans.
Iunderstand and agree to pay for any services related to legal matters, including but not limited to depositions, attorney phone calls, and court testimony; these services are a different pay rate.