Financial Responsibility ( 3 of 3 )

Please initial each of the following items:

 

 All professional services rendered are charged to the patient and are due at the time of service unless other arrangements have been made in advance with our business office. Necessary forms will be completed to file for insurance carrier payments.

 

             

Present initials to allow copays and other payments to be automatically charged to the card on file. By not signing, you are opting to pay invoices on your own and a 24-hour late fee will apply.

 

 

 

For insurance clients:

 

Assignment of Benefits

 

I hereby assign all behavioral health benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including private insurance, to issue payment checks directly to Mind Balance Neurofeedback/Shelli Myles’ behavioral health services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.

 

Authorization to Release Information

 

I hear by authorize Mind Balance Neurofeedback/Shelli Myles, LPC to: (1) release any information necessary to insurance carriers regarding my illnesses and treatments; (2) process insurance claims generated during evaluations or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims for the period of lifetime. This order will remain in effect until revoked by me in writing.

 

I have requested behavioral health services from Mind Balance Neurofeedback/Shelli Myles, LPC on behalf of myself and/or my dependents and understand that by making this request I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

 

I further understand that all fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. I understand that a 3% processing fee will apply to all debit/credit card payment transactions. A photocopy of this assignment is not to be considered as valid as the original.