Insurance as Payment: Eclipse Mental Health is only in network with Medicare/Medicaid and will submit claims in your behalf. You are responsible for any unpaid balance following submission and processing of insurance claims. For any commercial insurance that Eclipse Mental Health is not in network with, an invoice can be given for you to file and receive direct reimbursement from your insurance. Please be aware that benefits vary, and it is your responsibility to check with the insurance company regarding your policy and reimbursement with an invoice.
If your insurance changes, it is your responsibility to inform our staff. Any addition of secondary insurance to Medicare may result in a denial of claims.
ONLY FILL OUT THE FOLLOWING IF YOU ARE A SELF-PAY PATIENT
A card is kept on file to ensure payments are completed the day of your appointment. It is your responsibility to maintain an active and up to date credit card on file. If you cannot make your payment the day of your appointment, please let the office know in advance.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
CREDIT CARD GUARANTEE FOR PAYMENTS AND BALANCES
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