SAMPLE: Psychotherapist-Patient Services Consent Agreement (Continued)
Cancellation Policy: A $50.00 cancellation fee applies to any appointments not cancelled with 24-hour notice. You will be charged $50.00 for appointments that are missed and not cancelled (“no-shows”). Neither cancellations or no-shows are payable by insurance companies, they are solely the patient’s responsibility. Initial Insurance Authorization: It is your responsibility to arrange for initial insurance authorization or pre-certification as required by your insurance company. In addition, it your responsibility to immediately notify me if there are any changes to your insurance coverage. Your signature below indicates that you have read this entire agreement and agree to its terms. Further, you are giving Dr. Nusbaum permission to treat either yourself or your dependent child.
Your signature below serves as acknowledgement that you have reviewed the HIPAA Notice Form described above either in the office or on my website.
Insurance Authorization and Assignment I authorize Psychiatric Billing Services to apply for benefits on my behalf for covered services rendered by Mark N. Nusbaum, Ph.D. I understand that payment will be made directly to Dr. Nusbaum if he participates with my insurance plan. I certify that the information that I have reported regarding my insurance coverage is correct and further authorize the release of any necessary information to my insurance plan and Psychiatric Billing Services. I permit a copy of this authorization to be used in place of the original. This authorization may be revoked by me at any time in writing. I do not discriminate based on age, race, sex, religion, national origin, language, mental status, sexual orientation, gender identity, HIV status or disability.
Your signature below serves as acknowledgement that you have reviewed the HIPAA Notice Form described above either in the office or on my website.
Insurance Authorization and Assignment I authorize Psychiatric Billing Services to apply for benefits on my behalf for covered services rendered by Mark N. Nusbaum, Ph.D. I understand that payment will be made directly to Dr. Nusbaum if he participates with my insurance plan. I certify that the information that I have reported regarding my insurance coverage is correct and further authorize the release of any necessary information to my insurance plan and Psychiatric Billing Services. I permit a copy of this authorization to be used in place of the original. This authorization may be revoked by me at any time in writing. I do not discriminate based on age, race, sex, religion, national origin, language, mental status, sexual orientation, gender identity, HIV status or disability.