• Dr. Samuel Thielman

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  • Benefit Confirmation

    Insurance
  • FORM MUST BE COMPLETED PRIOR TO APPOINTMENT OR THE FULL AMOUNT OF YOUR VISIT WILL BE EXPECTED IN FULL

  • Please have your insurance card in hand

  • WHEN YOU CALL YOUR INSURANCE COMPANY ASK THE FOLLOWING QUESTIONS:

  • "This is (YOUR NAME) and I am calling to get details about my behavioral health benefits." 

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  • NOTE: Benefits Confirmation Form should be received by Biltmore medical prior to your first session in order for the office to verify your benefit. This allows our staff to calculate the payment you will be expected to make at the time of service. If this information is not received prior to your visit you will be responsible for the full fee amount until your benefits are verified or this completed form is received. Thank you.

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  • Cancellation Policy

    Please read and sign
  • If for any reason you are unable to attend your scheduled appointment you must call a minimum of 24-hours in advance. Charges arising from late cancellations or missed appointments without notice are not reimbursed by your insurance carrier, and will not be submitted to your insurer. Biltmore Medical is pleased to assist you by filing insurance on your behalf. An insurance policy is a contract between you and your insurance company. All deductibles, co-pays, and amounts not covered by your policy are your responsibility and you are asked to keep your account current at each visit. Our providers are participating providers with several insurance plans. However, you are ultimately responsible for payment of all services rendered, including those that are not covered by insurance.

    Fees and Unpaid Balances: The fee for your first appointment schedule will be discussed with you at your initial consultation or prior to your appointment if you wish. After the first visit, charges vary based on the complexity, duration, and treatment rendered during your visit. Physician providers (Psychiatrists) bill services in a manner similar to other physicians-that is a charge for an office visit typically combined with a separate charge for psychotherapy. Telephone and written communications with your provider may be subject to charges based on the duration of the service. Fees for Psychological Testing, Genetic Testing, and certain Consultations to coordinate care will be charged as separate services. We ask that you keep your account.

    Your rights as a Patient/Client: You have the right to ask questions about any procedure during therapy. You have the right to decide at any time to stop seeing your provider and if you wish, your provider will provide you with names of other qualified professionals you might prefer. You have the right to end therapy at any time without moral, legal, or financial obligation other than those already accrued.

    Authorization and Consent for Treatment: I hereby grant my authorization and consent to treatment and procedures deemed appropriate and certify that no guarantee or assurance has been made as to the results which may be obtained. I also give my consent for my personal health information to be shared with any other clinicians within Biltmore Medical Associates to which I have been referred.

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  • Insurance Authorization and Assignment: I hereby authorize Biltmore Medical Associates, to release information necessary to process insurance claims and request payments of benefits to be made to Biltmore Medical, for services rendered to my dependents or me. I understand that I am responsible for paying any required co-payments and deductibles at the time services are rendered. I hereby authorize my provider and Biltmore Medical Associates to release any information required by my insurance carrier to process insurance claims in the course of my examination or treatment. I authorize payment directly to the billing office for my provider and hereby assign payment for the medical benefits, if any, otherwise payable to me for services.

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  • Self-Pay: I have no insurance coverage or I waive the use of insurance. Therefore, I understand that I am responsible for payment at the time services are rendered to me. 

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