I understand that I have contracted for services with this provider and that I alone am responsible for paying the amount that is billed for services. In particular,

1. 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.
2. 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.
3. 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. Also, 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).
4. A fee of $95.00 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.
5. 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, letter writing, case management, etc. that take more than 15 minutes will be billed in 15 minute increments at $37.50 each. Insurance cannot be billed for either of these fees.
6. 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.
7. I also 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.