Southpointe Psychiatry & Wellness
PATIENT FINANCIAL POLICY
We are committed to building a successful provider-patient relationship. Your clear understanding of our Patient Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, our policies, or your responsibilities. A copy of the Patient Financial Policy will be provided to you upon request. It is your responsibility to notify our office if any patient information changes, for example, name, address, telephone, insurance information.
INSURANCE: We participate in most insurance plans, except Medicaid. If you are not insured by a participating plan, payment in full is expected prior to each visit. If you are insured by a participating plan but don’t have an up-to-date insurance card, payment is required if we can’t verify coverage. Failure to provide complete insurance information including secondary insurance will result in patient responsibility of the entire bill. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions regarding your coverage.
All patients must complete the patient information forms prior to seeing the provider. We must obtain a copy of your driver’s license, current insurance card, and credit card. If you fail to provide us with current information in a timely manner, you may be responsible for the balance of a claim.
SELF-PAY: We offer self-pay rates if we do not participate with your insurance or if you choose to opt-out of insurance reimbursement/submission. If this is a preference, please notify the administrative staff to discuss before your first appointment.
Initial, new patient psychiatric evaluation - $300.00
Follow-up patient evaluation - $150.00
INSURANCE CLAIMS SUBMISSION: We will submit claims and assist you in any way we reasonably can to get your claims paid. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claims. Your insurance benefit is a contract between you and your insurance company, we are not party to that contract. If your insurance company does not pay your claim in 60 days, the balance will automatically be billed to you. After 90 days of non-payment, the patient will be charged a late fee of $50 every month until the balance is paid in full.
CO-PAYMENTS & DEDUCTIBLES: All co-payments, deductibles, including past due balances must be paid at the time of service. This arrangement is part of your contract. Failure on our part to collect payments from patients can be considered fraud. To make payments convenient we accept most major credit cards, cash, checks, and HSA/FSA. The charge for a returned check or credit card due to insufficient funds is a $50.00 fee payable by cash. Additionally, future checks will not be accepted and all payments at the time of service must be paid via credit/debit card.
For clients participating in virtual appointments, only credit/debit cards are accepted forms of payment. A valid credit/debit card must be on file prior to your scheduled appointment as co-pays/deductibles are due at the time of service.
There will be no refund for out-of-pocket co-payments or insurance payments received for services rendered.
ACCOUNT BALANCE: Clients are responsible for any outstanding account balances NOT covered by insurance. This includes missed co-payments, no show/late cancellation fees, costs not covered by insurance. If payment is not made on the account, a single phone call and email or letter will be sent to try to make payment arrangements. If no resolution can be made after 60 days, the account will be in default with consideration for possible discharge from the practice. If this occurs, you will be notified by certified mail that you have 60 days to find alternative care. Clients may not be able to schedule upcoming appointments until their outstanding balance is paid in full. After 90 days of non-payment, the patient will be charged a late fee of $50 every month until the balance is paid in full. If you are facing financial hardships or are no longer able to afford services, please contact the administrative office to discuss payment options.
NO SHOWS/LATE CANCELLATIONS: A 24-hour advance notice is required for cancellation of any appointment. You are to call the office and/or leave a message regarding any cancellations. Emails or texts to the provider or office do not guarantee adequate notification of cancellations. Repeatedly missing appointments jeopardizes your care. For this reason, AFTER AN ESTABLISHED PATIENT HAS THREE (3) NO-SHOW AND/OR LATE CANCELLATIONS, the patient will be provided service for 30 days and may be discharged due to failed professional relationship. A NEW PATIENT HAS ONE (1) NO-SHOW OR LATE CANCELLATION, AND THEY WILL BE IMMEDIATELY DISCHARGED FROM THE PRACTICE.
Initial new patient intake appointments canceled with less than 24-hour notice will be charged a fee of $150.00. A client who fails to show for a scheduled initial new patient intake cannot reschedule future appointments.
Follow-up appointments canceled with less than 24 hours’ notice will be charged a fee of $75.00.
No-Shows (failure to not show for scheduled appointment) will be charged a fee of $75.00.
For medication refill requests due to late cancellations or not showing for your scheduled appointment, your credit card will be charged $20.00 on file.
MINORS: The parent(s) or guardian(s) is responsible for full payments and will receive the billing statements. A signed release to treat will be required for unaccompanied minors (less than 14 years old).
OTHER SERVICES: Any additional services such as formal letters, reports, school/work accommodations or written psychiatric evaluations will be charged a determined fee by the provider prior to completion as the insurance companies do not reimburse for the time and judgment that are required to complete these forms.
LITIGATION POLICY AND FEES: The providers at Southpointe Psychiatry & Wellness do not generally participate in client litigation or other adversarial proceedings. Your provider wants to protect your privacy and does not want to have to disclose your confidential information in court, even if that disclosure is with your written consent. The nature of the therapeutic process and medication management often involves making a full disclosure regarding legal matters which may be extremely private, upsetting, or embarrassing. If you become involved in any legal proceeding during your therapy or medication management with your provider (including but not limited to divorce and custody disputes, or personal injury lawsuits), you agree neither you, nor your attorneys, nor anyone acting on your behalf may subpoena records or testimony from your provider, or subpoena your provider to testify in court, in a deposition, or in any legal proceeding. By your signature below, you acknowledge and agree to abide by this litigation policy.
If contrary to this agreed upon policy, unforeseen circumstances require you to involve your provider in your litigation, or if you or your attorney(s) subpoena your provider, to provide records, testify in court, or give a deposition in violation of this litigation policy, we comply with lawfully issued subpoenas or other legal notices, but only upon receipt of your written authorization or a court order. Your provider’s hourly charge for all time related to court cases or litigation, including testifying in court or giving a deposition, we charge $500.00 per hour.
If your provider or staff are subpoenaed to provide records or testimony in violation of this litigation policy and against these stated wishes, you also acknowledge and agree you shall pay for all professional time, including but not limited to preparation, record review, transportation charges and time (door-to-door), waiting time, and time spent testifying in court or deposition regardless of which party issues the subpoena or requires your provider to testify.
Southpointe Psychiatry & Wellness is committed to providing the best care to our valued patients. Our prices are representative of the customary charges for our area. If you have any questions or need clarification of any of the above policies, please feel free to contact us.
SOUTHPOINTE PSYCHIATRY & WELLNESS RESERVES THE RIGHT TO CHANGE AND/OR MODIFY THE PATIENT FINANCIAL POLICY AT ANY TIME.
I HAVE READ AND UNDERSTAND THE FINANCIAL POLICY AND AGREE TO ABIDE BY ITS GUIDELINES:
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Patient Name/Responsible Party Date
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Signature