Terms of Service

Terms of Service

You must at 18 years old to receive services independently or accompanied by a parent/legal guardian. We reserve the right to refuse service in the event a patient becomes hostile, aggressive, or the relationship is not a good fit. We will send written notification to the email and home addresses that we have currently on file. By scheduling your appointment, you fully agree to all terms and conditions contained within this agreement. The scheduling certifies that you are the account guarantor and are accepting responsibility to pay for services rendered in accordance with the terms and conditions of this document.

General Terms of Payment

Payment for services is due to Quality Psychiatric Health and Wellness, A Professional Nursing Corporation (Quality Psychiatric Health and Wellness) at the time of your appointment. By scheduling, you authorize Quality Psychiatric Health and Wellness to charge your card on file for services rendered and acknowledge that to make appointments at Quality Psychiatric Health and Wellness, you must keep a valid credit card on file. You are responsible for maintaining a current billing address, mailing address, and credit card on file. Within 3 days of your appointment(s), the credit card that you put on file will be charged the amount due for cash pay or out-of-network insurance. If you have copayments, co-insurance, or unpaid deductibles, you will be charged according to your insurance benefits. The amount charged to your credit card on file will be based on the estimated level of service. In certain cases, the actual level of service may be less than the estimated level of service. If this is the case, you will receive a credit after the visit, in accordance with your insurance benefits. In other cases, the level of service may be more than the estimated level of service. If this is the case, you will be charged any additional amount owed in accordance with your insurance benefits. After your visits, you will receive an invoice explaining the amount charged to the card on file. If you do not receive an invoice, please contact us directly.

In the event that your insurance is in-network, you will be charged your responsibility at the time of the visit, such as any co-payments, co-insurance, and/or deductibles. If your insurance is not in network or you are not using insurance, then the cost of the service is $350 for an initial 75-minute Comprehensive Evaluation and $150 for follow-up appointments, at the time of service. Please understand that it is your ultimate responsibility to check and understand your benefits to determine whether your insurance company requires prior authorization before seeking services, a referral from your primary care provider for allowable costs for psychiatric services, the types of services covered, service exclusions, and how many visits are allowed. You are personally responsible for all allowable fees, as directed by your insurance company, as well as non-covered/allowed services. These fees are usually categorized as a co-pay, a co-insurance (percentage), or a deductible. Certain insurance plans will authorize a specific number of visits for a certain period of time. Please be certain that you are aware of your benefits, as you will be personally liable for any visits that fall outside of that coverage and are denied by your plan.

Reimbursement for In-Network and Out-Of-Network Insurance

For all appointments, payment is due at the time of service via credit card using the payment system and a credit card must be kept on file for your portion of the visit balance due. Within 3 days of your appointment(s), the credit card that you put on file will be charged the amount due for cash pay or out-of-network insurance. If you have copayments, co-insurance, or unpaid deductibles, you will be charged according to your insurance benefits. The amount charged to your credit card on file will be based on the estimated level of service.

If your insurance is out-of-network with Quality Psychiatric Health and Wellness and you wish to submit your bill to your insurance company, you can request an itemized summary of charges in the form of a superbill, which you can submit to your insurance company for reimbursement. However, Quality Psychiatric Health and Wellness can make no guarantee of any payment of services by your out-of-network insurance. In some cases the amount received from your insurance company may be less than the amount that you paid for the visit. In the event that your Coordination of Benefits (COB) for your insurance that you provide Quality Psychiatric Health and Wellness is not updated as your primary insurance, then your credit card on file will be charged the cash pay rate of the appointment(s) listed on the Quality Psychiatric Health and Wellness website. Once you update your COB and your insurance accepts claims, you will be charged according to your insurance benefits. Unpaid balances beyond 60 days will be sent to a collection agency.

We will submit claims only to the primary insurance carrier that you provide us. We do not bill secondary insurance. If you wish to bill your secondary insurance, we can provide you with an itemized list of charges in the form of a superbill. If your secondary insurance does not pay your claims, it will be your responsibility to contact this carrier to resolve any issues of coordination with coverage. In rare instances, but not limited to, a weekend, holiday, or clinical closure, your charge card on file may be charged greater than 3 days in advance of your appointment. In the event that an additional amount is owed, such as, but not limited to, cash pay rates due to out-of-network insurance or additional amounts not covered by insurance, then you authorize Quality Psychiatric Health and Wellness to charge your card on file the additional balance owed.

Cancelation Policy

All cancelations or rescheduling must occur at least 48 hours prior to your scheduled appointment. Your time is valuable to us and when you make an appointment, we commit to being available to only you at that time. Therefore, to confirm and reserve your appointment, your credit card will be charged accordingly. We understand that life can be unpredictable. If an appointment change is necessary, please email or call us to reschedule/cancel your appointment at least 48 hours before your appointment time. Failure to reschedule or cancel 48 hours prior to the scheduled appointment will result in a nonrefundable 100% service charge. Our goal is to collaborate with you for the best possible outcome. If you arrive more than 30 minutes late to an initial appointment and 15 minutes late to a follow-up appointment in which you are not signed into the telepsychiatry software or checked in, then the appointment will be counted as a missed appointment and you will be charged in full. NO SHOWS will be charged a 100% service fee.

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