Common Contracts
2 similar Financial Policy and Patient Agreement contracts
Financial Policy and Patient AgreementFinancial Policy and Patient Agreement • September 11th, 2020
As a courtesy, I will bill your insurance company, HMO, responsible party, or third party payer for you. In the event you have not met your deductible, the full fee is due at each session until the deductible is satisfied. If your insurance company denies payment or does not cover counseling, I request that you pay the balance due at that time. If you make a payment by check and that check is returned for insufficient funds, your account will be charged a $35.00 fee. You agree that in the event your account is turned over to a collection agency or attorney due to non-payment, you will pay an additional 33.3 percent of the balance as reasonable collection fees (to be added to the balance at the time the account is placed for collection) plus any court costs and attorney's fees incurred in connection with the collection of your account. I ask that you authorize payment of medical benefits directly to K&B Counseling Services, LLC (the Practice).
Financial Policy and Patient AgreementFinancial Policy and Patient Agreement • September 8th, 2020
As a courtesy, I will bill your insurance company, HMO, responsible party, or third party payer for you. In the event you have not met your deductible, the full fee is due at each session until the deductible is satisfied. If your insurance company denies payment or does not cover counseling, I request that you pay the balance due at that time. If you make a payment by check and that check is returned for insufficient funds, your account will be charged a $35.00 fee. You agree that in the event your account is turned over to a collection agency or attorney due to non-payment, you will pay an additional 33.3 percent of the balance as reasonable collection fees (to be added to the balance at the time the account is placed for collection) plus any court costs and attorney's fees incurred in connection with the collection of your account. I ask that you authorize payment of medical benefits directly to K&B Counseling Services, LLC (the Practice).
