Diane Privitor Davis, APRN, FNPC, PMHNP-BC
Financial Policies Agreement
1501 Royal Ave
Monroe, LA 71201
P; (318) 816-5116  F: (318) 855-3429

FINANCIAL POLICIES AGREEMENT

• Payment for services provided by Therapeutic Medical & Psychiatric Services is due at the time services are rendered
• Unless payment by health insurance has been arranged prior to the visit.
• If insurance coverage has ben arranged, payment of any applicable copayment or deductible is due at the time services are rendered.
• If we do not have a contractual provider relationship with your insurance plan, full payment for services is due at the time services are provided.  We will help you bill your insurance
• You agree to be fully responsible for payment for all services not covered by your insurance.  If there is a problem with your insurance coverage you agree to pay your bill and deal with your insurance company yourself.
• As a courtesy to you, we will attempt to verify your insurance coverage and determine you insurance benefits.  However, if your insurance company has misinformed us or you feel we have misinformed or failed to adequately inform you regarding your benefits, you are still responsible for payment of all charges not covered by your insurance.  We encourage you to verify your insurance benefits and coverage yourself and to make sure that you fully understand your coverage.  By signing this agreement, you agree to be responsible for all charges for the client identified below, even if you believe that some other party should bear responsibility for these charges.
• Some services may not be covered by health insurance.  You agree to be fully responsible for payment for all services that are not covered by your insurance plan.  This may include charges for telephone consultation, written correspondence or reports in connection with a client's evaluation or treatment, including consultation or correspondence with the client, family members, past or current treatment providers, educational professionals, attorneys, courts, agencies or others.
• When an appointment is missed or cancelled without at least 24 hours prior notification, a $50.00 fee applicable to the cancelled appointment may be charged.  If the appointment falls on the first business day of the week, notification of cancellation must be received by noon of the last business day of the preceding week.  Fees charged for missed appointments or late cancellations must be paid prior to the next appointment. 
• Payment of any outstanding balance that is your responsibility is due promptly upon receipt of a billing statement or at your next visit, whichever comes first.
• For self-pay balances over 60 days past due a service charge will be added by each 28 day billing cycle equal to 1.5% of the outstanding balance or a minimum of $5.00.
• For self-pay balances over 100 days past due, the minimum service charge will be $10.00.
• A charge of $25.00 will be applied for all checks returned unpaid.  If an overdue account is sent to a collection agency, collection fees and expenses will be added to the amount due.
• A copy of the currently applicable fee schedule of Therapeutic Medical & Psychiatric Services will be available on request.  Fees may be modified without notice. 

ACKNOWLEDGEMENT AND AGREEMENT

• I have read the above and affirm that everything in this form that was not clear to me has been explained to my satisfaction.
• I understand that it is my responsibility to know my insurance benefits.  I hereby agree to abide by the policies specified above and to be responsible for all fees and charges for the services provided by Therapeutic Medical & Psychiatric Services LLC to or on behalf of the client named below.  This agreement will continue as long as Therapeutic Medical & Psychiatric Services LLC provides services or until a written request that this agreement be terminated is received by Therapeutic Medical & Psychiatric Services LLC.  

Assignment of Health Insurance Benefits:  The signature below authorizes payment directly to Therapeutic Medical & Psychiatric Services LLC of benefits payable under the health insurance policy covering the client named below.  

• For Medicare Clients Only:  The undersigned hereby requests that payment of authorized benefits be made to Therapeutic Medical & Psychiatric Services LLC on behalf of the client named below. 

The undersigned authorizes any holder of medical information about the client to release to the Client's Individual Insurance Companies and its agents any information needed to determine those benefits or the benefits payable for related services.  A photocopy of this form is to be considered as valid as the original.