Radiant Being Psychological Services, PC. is committed to providing you with the highest quality care in a warm, supportive environment. To avoid any confusion or unexpected expenses, patient and insurance responsibility for payment of services is best made clear before treatment begins. Please read this financial agreement carefully, ask us any questions you may have, and sign in the space below. If you wish, you may print a copy to refer to in the future.
RBPS is a participating provider with a number of insurance plans, including, but not limited to Highmark Blue Shield, Pennsylvania Blue Shield, Capital Blue Cross, Medicare, and Aetna. Even if we do not participate with your health insurance, your plan might cover part of the fee. In general, if you have a health insurance, it may provide coverage for part of the fees for mental health treatment. My billing staff and I will submit claims to insurance companies and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental and behavioral health services, including, but not limited to, the maximum number of sessions allowed per year. If you have questions about the coverage, call your plan administrator or the customer service number on the back of your insurance card. Of course, we will provide you with whatever information we can based on our experience and will be happy to help you in understanding the information you receive from your insurance company.
Insurance – I participate in many insurance plans. If you are not insured by a plan in which I participate, payment in full is expected at each visit. If you are insured by a plan I do participate with, but do not have your insurance card, or an up-to-date insurance card, payment in full is expected at each visit until coverage can be verified. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. If your insurance company does not pay your claim for any reason, the balance will be your responsibility.
Co-payments and Deductibles – All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company, and waiving your co-pay and deductible is not permitted by my contract with insurance companies. We will give you our best estimate of what the co-pay should be for each visit. For many policies, the co-pay may change during the course of your treatment and insurance plans can change without notifying providers. The only way we can confirm exactly what a co-pay should have been is by reading the materials that come to us from the insurance company after the session is billed and paid. You may receive a copy of this Explanation of Benefits (EOB) from your insurance company. If your co-pay was higher than collected, you are responsible for paying the difference. If it should have been lower, we will give you a refund or credit.
Non-covered Services – Please be aware that some- and perhaps all- of the services you receive may be non-covered or not considered reasonable or necessary by your insurer. You must pay for these services at the time of service or within 30 days of the billing statement to avoid incurring a late payment fee.
Invoices – Invoices shall be deemed to be accepted by you unless Radiant Being Psychological Services, PC is notified in writing within 14 days of issue of the invoice you wish to dispute. In the event of non-payment, Radiant Being Psychological Services, PC may add to the invoice amount charge: (i) Interest on any outstanding amounts from the due date calculated at the statutory penalty rate of 6%. If any part of your account with Radiant Being Psychological Services, PC is not paid within 31 days, then the totality of that account, whether or not past due, shall become immediately due and payable. If non-payment continues to be an issue, I may decide to end your treatment relationship with me. If that occurs, I will discuss it with you, and will offer you referrals to other mental health providers with whom you can continue treatment.
Proof of Insurance – All patients must complete our patient information form before seeing a therapist. We must obtain a copy of your driver’s license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, or if you falsify insurance information, you may be responsible for the balance of the claim. In addition, the event of falsification of insurance, we may report you to the appropriate legal entity for prosecution.
Claims Submission – We will submit information about your treatment as part of your claims, and we will assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.
Coverage Changes – If your insurance changes, please notify us before your next visit so that we can make the appropriate changes to help you receive your maximum benefits. If you fail to notify us of insurance changes in a timely fashion, you may be responsible for your entire bill.
Non-payment and Collections – If your account is over 31 days past due, you will receive a letter stating that you have 14 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid for 60 days, our policy is to refer your account to a collection agency authorized to credit report all outstanding debts to the four major National Credit Agencies and/or litigate in a court of law. You will be required to reimburse Radiant Being Psychological Services, PC any collection agency fees, which may be based on a percentage at a maximum of 30% of the debt, and all costs and expenses, including reasonable attorneys’ fees, we incur in such collection efforts.
Missed Appointments – In order to have adequate notice so we can offer other clients in need of an appointment the cancelled hour, we require 48 hours’ notice if you need to cancel an appointment (cancelations for Monday appointments require 72 hours notice). You will be charged a $50 fee for any missed appointment or appointment canceled with less than 48 hours’ notice. These charges will be your responsibility (insurance companies do not provide reimbursement for canceled sessions) and billed directly to you. Please help us to serve you, and all of our clients, better by keeping your regularly scheduled appointments or calling 48 hours prior to your appointment. In addition, more than 3 missed or canceled appointments (regardless of payment of cancelation fee) within a 6 month period will result in discharge from treatment. If this does occur, we will discuss the reasons for termination of treatment and you will be provided with referrals to other mental health providers for treatment.
Other Charges – The fee for a returned check is $25. In addition, please note: We will not accept additional checks after two checks are returned. The fee for completing forms or requests for preparation of letters (disability, life insurance, etc.) is $25. Fees for copying records (except when sent to another health professional) are charged per page ($1.00 / page). The fee for telephone contact longer than 15 minutes in duration is $25 for 30 minutes (after the first 15 minutes).
Forms of Payment Accepted – Cash, personal check, credit card (Visa, MasterCard, Discover, American Express), and HRA / FSA cards (healthcare reimbursement or savings accounts).
Radiant Being Psychological Services, PC, is committed to providing the best treatment to our clients, and our payment policies are designed to support us in our ability to provide excellent care. Thank you for reading, understanding, and complying with our payment policy. Please let us know if you have any questions or concerns.
I have read and understand the payment policy and agree to abide by its guidelines:
Signature of patient or responsible party Date