Financial Policy, Patient Responsibilities & Insurance Disclaimers

Battlefield Counseling Centers

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Financial Policy Statement

Welcome to the office of Battlefield Counseling Centers. We are pleased you have chosen our practice for your therapeutic care. We ask that you carefully read and sign the following statement. We must emphasize that, as your clinical provider, our relationship is with you and not your insurance carrier. As a courtesy to you, we will file your claim with your insurance company. However, you are the sole responsible party for all charges incurred and guarantee payment thereof. Benefit eligibility obtained from your insurance company is for informational purposes only and not a guarantee of payment. If we are contracted with your insurance company, we will accept assignment. You will be responsible for your payment portion at the time of service. All balances become your responsibility when the account reaches 45 days from the date of service. Failure to provide necessary referrals and/or authorizations or failure to provide current, accurate billing information will result in all charges for services becoming the sole responsibility of the patient/responsible party. You are expected to understand your benefits coverage and responsibilities. This includes obtaining any referrals and/or authorizations which your insurance company might require before care is provided.

All co-pays, co-insurance and deductibles are due and payable at the time services are rendered. If we do not have a contractual obligation with your insurance company, you are responsible for 100% of the payment at the time services are rendered.

All account balances still owed to Battlefield Counseling Centers or Faith James LLC when the account reaches 75 days from the date of service it will be referred to an outside agency for collection. Accounts referred to a collection agency will incur a fee of 28% of the principal balance, to cover collection/attorney fees and interest.

In consideration of the services performed by Battlefield Counseling Centers or Faith James LLC, you agree to abide by the terms of this Financial Statement.

I hereby authorize Battlefield Counseling Centers or Faith James LLC, to apply for benefits on my behalf for services rendered. I certify that the information I have provided is correct. I authorize the release of any necessary information, including medical information for this or any related claim to the health insurance I have provided. Should collection action become necessary, I further authorize the release of demographic information including cell phone numbers to outside agency to facilitate collection of my debt. I permit a copy of the authorization to be used in place of the original. I may revoke this authorization at any time in writing.

By typing my name below, I acknowledge my understanding of the information printed above. I agree this electronic signature is the legal equivalent of my manual signature on this document.

Patient Responsibilities

Please notify us of any changes in your address, phone or insurance information at the time of the change.

By presenting to us for treatment we will file your claim if we participate with your insurance plan. It is your responsibility to research your coverage and requirements to ensure payment for services rendered, co- payments/co-insurance, prior authorizations needed and clinician’s status as an in-network participating provider. If you accept services without getting the proper referral or prior authorizations you understand that this means you become responsible for this service. If we do not participate with your insurance, we will be happy to provide you with the information required to submit a claim for reimbursement. Please note, you will asked to pay in full at the time of service. Please be advised that we do not bill to secondary insurances.

All appointments must be scheduled in advance. As a courtesy, it is important to keep all scheduled appointments. There will be $50.00 fee for missed appointments due at the beginning of the next scheduled appointment To avoid this fee please call 48 hours in advance.

Co-payments/co-insurance must be made at the time services are rendered. (This is a health insurance requirement.) Pay your bill promptly. If there is financial hardship, please call (703) 629-9116 and ask for billing in advance of appointment.

There is a $15 fee for preparing/copying/mailing all medical records. Records take 14 days to process so make sure your release form is turned in within the appropriate timeframe. All medical records are kept for six (6) years from the last date of service and are then destroyed.

There is a $35.00 fee on all returned checks.

There is a $65.00 charge to complete any kind of form for life insurance, school, employment or disability forms. Payment is due when the form is turned in. Please give us at least 7 business days to complete the form.

Under certain circumstances a client may opt for a phone session. If held, there will be a $65.00 fee charged per 30 minutes. This charge is not billable to insurance, thus is the responsibility of the client. The reason for this charge will be explained to you if/when applicable.

I have read and understood the above policies.

By typing my name below, I acknowledge my understanding of the information printed above. I agree this electronic signature is the legal equivalent of my manual signature on this document.

Insurance Coverage Disclaimer/Financial Policy

Due to the recent and unpredictable changes within the insurance industry, effective immediately, Battlefield Counseling Centers is requesting all patients to verify and be familiar with their insurance benefits prior to being seen in our office. As a courtesy, our staff will continue to verify and bill your insurance but we cannot guarantee coverage or that the information we have received from your carrier and conveyed to you is accurate or complete. Please read and sign that you have received and understand the following:

I understand that Battlefield Counseling Centers will bill most insurance carriers and that all co-pay and deductible amounts are expected to be paid at the time of my appointment unless other arrangements have been made in advance. Should I have a balance for any reason after my insurance has processed the bill, it will be my financial responsibility to pay this balance due.

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I understand that if my insurance company requires preauthorization it is my responsibility to obtain this authorization prior to my appointment. I accept the full responsibility of keepng track of the number of visits allowed and the number of visits used. It is my responsibility to track the expiration date, the referral, and preauthorization even if those services were performed within another facility or clinic.

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I have read and understand that if my insurance does not pay in full for the services provided by the providers at Battlefield Counseling Centers, I assume liability for the allowed unpaid portion.

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I authorize the release of any records that might be necessary to facilitate payment of services and authorize the insurance company to make payments directly to Battlefield Counseling Centers and/or provider. It is understood that my health care information may be released and discussed with other providers/physicians directly involved in my care.

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I also understand that it is my responsibility to fully understand my insurance benefits and that the benefits quoted to me by this office are based on information provided to Battlefield Counseling Centers by my insurance carrier. I understand that Battlefield Counseling Centers must abide by the rules governing my insurance coverage, but ultimately coverage is based upon my contractual agreement with my insurance carrier. All services are subject to medical necessity. I futher acknowledge that if it is requested of me, that I agree to assist my provider in obtaining the proper documentation and/or referrals to substantiate the medical necessity of my treatment.

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I understand that services provided by Battlefield Counseling Centers are not covered by Medicare and therefore will not accept Medicare patients. If I have Medicare I acknowledge I am a private pay patient and agree to pay all fees at the time of my appointment.

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I understand that keeping appointments or canceling them with adequate notice (i.e., 48 hours prior to the appointment time) is my responsibility. Otherwise, I will be charged a late cancelation fee of $50.00 which will be charged to my credit card.

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Due to security reasons you are unable to sign this form electronically. In lieu of an e-signature, please note that you acknowledge and understand the content of this form by typing your name in the field below. You agree your electronic signature is the legal equivalent of your manual signature on this document.

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