CONTRACTUAL AGREEMENT FOR BILLING AND PAYMENTS
Rick D. Thomas, Ph.D.
This office is committed to providing you with the best possible care. If you have medical insurance, I am anxious to help you receive your maximum allowable benefits. In order to achieve these goals, I need your assistance and your understanding of my payment policy.
Payments for services are due at the time services are rendered unless payment arrangements have been approved in advance. I accept cash, money order, or check. I will be happy to help you process your insurance claim form for your reimbursement. A complete insurance form must accompany any such request. Upon verification of your insurance benefits, I will accept assignment of benefits when accompanied by the percentage due from the patient at each visit at time of service.
Returned checks and balances older than 60 days will be subject to additional collection fees and interest charges of 1-1/2 percent per month, 18% APR. This charge will be added to all overdue accounts. All balances not paid within 60 days are due in full or will be submitted to my Collection Agency. All delinquent accounts will be subject to a $9.00 per month late fee regardless of balance in addition to interest and collection agency charges. Charges will also be made for broken appointments and appointments canceled without 24 hours advance notice. Any court costs incurred for the collection of your account will be added to your account. You are also liable for any legal and collection fees resulting from your past due account. All returned checks will be subject to a $35 service fee.
If I am required to testify in court on your behalf for any reason, you will be charged an hourly rate for my services. Charges shall be calculated for actual time away from my office on a flat hourly rate. This hourly rate shall be $250 per hour, immediately due and payable by check or cash.
I will gladly discuss your proposed treatment and answer any questions relating to your insurance. You must remember that your insurance is a contract between you, your employer, and your insurance company; therefore any problems arising with your insurance carrier are your responsibility.
I must emphasize that as a provider of psychological services, my relationship is with you, not your insurance company. While the filling of insurance claims is a courtesy that I extend to my patients, all charges are your responsibility from the date the services are rendered.
I realize that temporary financial problems may affect timely payment of your account. If such problems do arise, I encourage you to contact me promptly for assistance in the management of your account. Remember that I am a psychologist, not a lending institution.
If you have any questions about the above information or any uncertainty regarding insurance coverage, PLEASE don't hesitate to ask. I will be glad to help you.
Your signature on this authorizes disclosure of information about you to a collection agency for collection of a past due account. Understand that your credit rating will be adversely affected by nonpayment of your account.
I understand and have received a copy of the above financial policy.
Signature of client Date