Private Pay Agreement

Name of Patient

Date of Birth

Example 05/30/2010

You are registering as a private-pay patient with Advanced Behavioral Health Center. This means that at the time of service, you will be paying by cash or debit/credit card. Advanced Behavioral Health Center will make no attempt to bill your insurance provider for services provided under this private-pay agreement.

By "signing" below, I confirm my understanding that no attempts will be made to bill third-party payers

By "signing" below, I confirm that the charges presented to me are due one business day prior to my scheduled appointment

By "signing" below, I confirm that I understand I will be responsible for all charges related to the services provided to me by Advanced Behavioral Health Center

*Please initial each item below to indicate that you have read, understand, and agree to the following*

I am choosing to not use my health insurance coverage to pay for services provided by Advanced Behavioral Health Center (ABHC).

I understand that ABHC will not bill any third party or insurance company for services or fees incurred for services provided by ABHC.

I understand that I am solely responsible for any fees incurred while in treatment with ABHC

To complete your registration as a private pay patient, please carefully read the following Credit Card Authorization.

Advanced Behavioral Health Center, Credit Card Authorization for Virtual Appointments

I, the undersigned, authorize Advanced Behavioral Health Center to charge my card on file for the amounts owed by me to include co-pays, deductibles, and "no show" fees. (Please note: This does not include past-due balances.) I understand that I will be sent receipts for credit card charges via email and that such charges will appear on my credit card statement. I understand that a credit card is required to be on file prior to telehealth services being rendered. I understand that this Credit Card Authorization will remain in effect until I provide written notice of cancellation to Advanced Behavioral Health Center.

*Please note: All virtual/telehealth patients must keep a card on file with ABHC and agree to pay for services one business day prior to their appointment.

With which health insurance company are you insured?

I understand no Prior Authorizations will be obtained for non-participating providers

Email address for Virtual/Telehealth receipts

Self-Pay Rates:

Physician Appointments, New Patient Evaluation: $400.00

Physician, Follow-Up Appointments: $200.00

Therapy Sessions, New Patient: $175.00

Therapy, Follow-Up: $140.00

I have read and fully understand the above self-pay rates and I agree to waive insurance billing.

I agree to pay the costs associated with my visit at or before the time services are rendered by ABHC.

Responsible Party's Name

Relationship to Patient

Signature (Type name if completing online)

Today's Date

Full Name as it appears on Debit/Credit Card

Expiration Date

Debit/Credit Card Number

CVV

(Typically, 3 digits on back of card)

This version created on March, 2, 2023 by CMcD

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