FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • July 25th, 2023
• You agree to provide GWOA/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • April 2nd, 2021
• You agree to provide SCC/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • November 22nd, 2021
• You agree to provide PO/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • July 24th, 2020
If I do not have a contractual provider relationship with your insurance plan, full payment for services is due at the time services are provided. I will provide you with receipts for your insurance so they may possibly reimburse you.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • June 3rd, 2020
• You agree to provide MCS/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • March 18th, 2020
• You agree to provide CCBD/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • September 17th, 2021
• You agree to provide CBSNV/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • October 20th, 2021
• You agree to provide HOI/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • June 22nd, 2021
• You agree to provide DHO/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • December 13th, 2023
• You agree to provide WCI/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • October 30th, 2019
• You agree to provide VO/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • February 19th, 2020
• You agree to provide WHO/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • March 27th, 2023
• You agree to provide LSO/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • August 11th, 2023
• You agree to provide CCBD/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • July 22nd, 2020
• You agree to provide LCCC/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • July 24th, 2019
• You agree to provide HOC/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • February 9th, 2022
• You agree to provide CBSG/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
Tranquility Integrated Care, PLLC. PoliciesFinancial Policies Agreement • April 24th, 2020
Payment for services provided by the Tranquility Integrated Care is due at the time that services are rendered. If the patient is covered under insurance, payment of any applicable co-payment, co-insurance, or deductible is due at the time of service. If Psychiatric Wellness Center is not contracted with the insurance, payment for services is due in full at the time that services are rendered. Insurance will be billed on your behalf and you will be reimbursed any applicable credits. Tranquility Integrated Care makes every effort to verify your coverage with your
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • April 14th, 2023
• You agree to provide FOH/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • April 27th, 2020
• You agree to provide OHA/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • November 2nd, 2020
• You agree to provide CBSA/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • September 10th, 2020
• You agree to provide HOH/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • August 12th, 2021
• You agree to provide PCSC/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • June 22nd, 2023
• You agree to provide TCU/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • October 21st, 2021
• You agree to provide MCC/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • July 26th, 2021
• You agree to provide GCBI/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • October 20th, 2021
• You agree to provide GOHC/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
Loudoun Psychiatric Care.Financial Policies Agreement • June 13th, 2015
If you have medical insurance, we are eager to help you receive maximum allowable benefits. In order to achieve this goal, we need your assistance and your understanding of our payment policy. You will be asked to update your personal and insurance information periodically, including providing our office with copies of your information to your insurance card and driver’s license. We are required by law to obtain your signature for permission to release information to your insurance carrier. Our failure to obtain these updates could result in criminal and civil penalties and/or expulsion from your insurance plan. Please assist us in complying with your insurance requirements. We will gladly submit fees for you covered medical services to your insurance company, if your provider is considered in network. However we expect payment of all services rendered within 60 days. It may become necessary for you to pay your account in full if your insurance company fails to pay for services within
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • November 27th, 2023
• You agree to provide BHO/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
This agreement supersedes all previous related agreements.Financial Policies Agreement • January 6th, 2007
If you have medical insurance, we are eager to help you receive your maximum allowable benefits. In order to achieve this goal, we need your assistance and your understanding of our payment policy. You will be asked to update your personal and insurance information periodically, including providing our office with copies of your insurance card and driver’s license. We are required by law to obtain your signature for permission to release information to your insurance carrier. Our failure to obtain these updates could result in criminal and civil penalties and/or expulsion from your insurance plan. Please assist us in complying with your insurance requirements. We will gladly submit fees for your covered medical services to your insurance company, if your provider is considered in- network. However, we expect payment of all services rendered within 60 days. It may become necessary for you to pay your account in full if your insurance company fails to pay for services within 60 days. It
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • July 21st, 2022
• You agree to provide GSCBS/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • February 15th, 2024
• You agree to provide HCC/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
FINANCIAL POLICIES AGREEMENTFinancial Policies Agreement • February 28th, 2024
• You agree to provide LCR/AOP with current and accurate insurance, health care benefits program and/or other payer information, and to immediately notify us if your coverage changes.
APPENDIX A: FINANCIAL POLICIES AGREEMENT: Financial Policies Agreement • October 28th, 2021
Payment: The fee per fifty (50) minute session shall be: $ (the “Hourly Rate”). A bulk purchase of ten (10) sessions (a “Package”) may be purchased at the cost of $ (the “Package Cost”). Payment is due prior to the start of in-person sessions, and 24 hours in advance of any virtual/phone session.
