I, _____________________, understand that I have contracted for services with Lisa Fields, APRN, and that I alone am responsible for paying the amount that is billed for services. In particular,
- I understand that PCA Resources, Inc. provides insurance filing as a courtesy and a convenience to me and/or will seek authorizations from my health care provider; however, these activities do not guarantee that my insurer will pay. I understand that at any time I am free to file my own insurance, in which case full payment of fees will be required at the time of service.
- I understand that the business office will attempt to help me understand my insurance or managed care benefits and procedures, but that denial of benefits by my insurer means that I am fully responsible for the contracted amount.
- I understand that I am responsible for meeting the requirements of my health insurer or managed care provider. In particular, I am responsible for:
- Obtaining the initial referral to the provider, if needed.
- Ensuring I have pre-certification of visits, if needed.
- Knowing limits regarding my deductible.
- Keeping track of benefit limits. Keeping track of my benefits entails knowing any limits on my policy and ensuring that I do not exceed those limits (e.g., some insurers set a maximum of 20 mental health sessions per year). If I exceed my limits and my insurer refuses to pay, I will be responsible for the amount refused.
- I understand that if I am seeing another social worker, psychologist or psychiatrist, those sessions may count against my mental health benefits. I also realize that while my managed care provider may authorize visits as appropriate for me, that does not mean that they will necessarily pay for those visits (e.g., Some insurers will authorize 35 visits when they will only pay for 30 visits).
- I understand that a fee of $109.00 per scheduled hour will be charged if I do not give a 24 hour notice (during normal business hours) to cancel an appointment, with the exception of mutually agreed upon emergencies. Insurance cannot be billed for this fee, as they will not pay for missed appointments.
- I understand that Lisa Fields, APRN, is not responsible for lost or stolen prescriptions. Any lost or stolen prescription that needs to be replaced will be subject to a charge of $10.00.
- I understand that any other work, such as letters, phone calls, case management A fee of $37.50 will be charged to my account for every 15 minutes I am late for a scheduled appointment. In addition, any other work, such as phone calls, letters, case management, disability paperwork (i.e. TEFRA,etc.) that takes more than 15 minutes to complete, will be billed in 15 minute increments at $37.50 each.
- I understand that if my policy changes or if I switch insurance companies, I should inform the office immediately. If the office does not have the proper information and cannot collect payment from the insurer, I am responsible for the amount the insurance company will not pay.
- I understand that in the instance of my account getting turned over to collections that I am responsible for the entire bill plus 100% of collection fees.
PATIENT RESPONSIBILITY FOR LITIGATION
I, ________________, understand that I have contracted for psychiatric services with Lisa Fields, APRN, and that I alone am responsible for paying the amount that is billed for services.
- Due to the complexity and difficulty of legal involvement, Lisa Fields, APRN, charges $300.00 per hour for preparation and attendance at any legal proceedings.
- Court appearances are charged in 4 hour increments (e.g. 8:00 am to 12:00 pm or 1:00 pm to 5:00 pm, at $1,200.00 per half day). These charges apply regardless of whether testimony is given.
- Payment will be required in full by 5:00 pm 3 business days prior to the scheduled court proceedings. In the event that the case is settled or less time is required, the excess amount paid will be promptly refunded.
- We cannot bill your insurance company for any charges related to litigation.
- If a third party, such as your attorney, is responsible for the fees incurred it is your responsibility to ensure payment. If the third party, even if contractually obligated to pay, does not pay, I, __________,
- will be responsible for the full balance plus any additional fees incurred if the account is referred to an attorney for collection.
- a. If a third party is responsible for payment, the obligations must be in writing, signed, and preserved.
- b. Payment will be required in full by 5:00 pm 3 business days prior to the scheduled court proceedings.