Financial Agreement Form
Thank you for choosing our office for your Mental Health needs. Please read the following information and sign below.
Insurance-In Network Carriers: Graceland Psychiatry will submit insurance claims for in-network insurance carriers only. Patients will be responsible for all Deductibles and Copayments at the time of service. Patients will be liable for any balance that is not collected from the third-party payer. Our office will attempt to appeal a denied claim, 1 time, if possible.
Insurance-out of Network: Patients may request a receipt to submit to out-of-network providers (Excluding Medicare) Payment is due at the time the service is rendered.
Private-Pay: Patients must pay, in full, at the time of service. Payment Options: Debit or Credit Cards (Visa, MasterCard, and Discover) Flex Spending or Cash. No checks will be accepted. Credit card must be issued in the patient’s name. We do not accept payments via telephone.
These administrative fees are not billed to your insurance company as they are not reimbursable. Payment of these fees are due at the time the forms are picked up; Missed appointment/late cancellation fees will be collected at the next office visit prior to being seen by your provider.
- Canceled/rescheduled office visits less than 24 hours prior to appointment: $25.00
- No show for Appointment: $50.00
- Form fee: $15.00 per form
- Duplicate receipts/copies of medical records: $0.76 per page
- New Patient Medication visit: $250.00
- Medication Follow Up $150 Monthly/$75 Bi-weekly
- New Patient Counseling visit: $150
- Counseling Follow Up: $75
I have read the information above and acknowledge my understanding of the policy concerning financial matters.
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