INTROSPECT FEE AGREEMENT
Patient: ___________________Responsible Party:_____________________
1. I understand that fees are due at the time of each appointment and that I may not schedule an appointment until all copays, deductibles or any other out-of-pocket fees are paid.
2. I understand that I am responsible for payment of services provided by INTROSPECT providers and that balances (over 30 days) are subject to collection fees and/or interest of 1 ½% per month on the unpaid balance.
3. It is my responsibility to know my insurance benefits. I understand that I am responsible for monitoring my insurance payments to INTROSPECT and that I am responsible for all balances not paid by my insurance company.
4. I understand that
it is my responsibility to notify INTROSPECT in advance of any change
to my insurance plan or company, or to my address or telephone number.
HMO PATIENTS PLEASE NOTE: CHANGING YOUR PRIMARY CARE PHYSICIAN
MIGHT RESULT IN YOUR INSURANCE NO LONGER COVERING TREATMENT AT INTROSPECT.
5. Sometimes an insurance company reimburses their member a portion of the fee that is due to INTROSPECT. In the event that this occurs, I agree that within 5 days, I will sign the insurance check over to INTROSPECT.
6. Returned Check Policy: I agree to pay Introspect a $25 charge for returned checks.
7. Other Professional Services: Requests for reports, completion of forms, attending meetings on behalf of you or your child, and phone calls in excess of 5 minutes, will be charged to you on a prorated basis at INTROSPECT’S standard fees of $125 per hour for therapists and $180 for psychiatrists. Insurance companies do not pay for ancillary services thus you will be directly responsible to pay for these services. These fees do not apply to communications with your family physician or for coordination of care with other doctors or specialists. Special fees apply for services related to legal matters. Please check with our administrative staff or your therapist regarding these fees.
8. Cancellation Policy: There will be a charge of $63 for missed appointments and appointments not cancelled at least 24 hours in advance. (The fee is $50 for brief medication checks with psychiatrists.) Insurance companies do not pay missed appointment/late cancellation fees. This fee is not meant to be a penalty. As might be the case with your family doctor’s office there are no other patients waiting if you do not appear. Therefore, if an appointment is missed or cancelled with short notice, our office will not be able to fill that time. The only exception is a bona fide medical emergency. A general medical illness is not an exception. In the event of severe weather conditions, you will be charged for missing or canceling your appointment unless the local or state authorities have declared an official emergency that forbids driving on the roads. We recommend that should you have any doubts about your ability to keep your appointment, simply cancel 24 hours in advance.
9. Medication Refills: You must carefully monitor your medications and arrange for an appointment with your psychiatrist prior to exhausting your supply. Because it is time consuming for your psychiatrist to phone in a prescription and takes away from servicing other patients, a fee of $25 will be assessed to you if your medication must be phoned in.
I understand and agree to all of the above:
Signature :
_______________________________________Date:_________
Responsible Party
.