Your Agreement of Financial Responsibility When Receiving Services at Hobble Creek Behavioral Health

This Payment Agreement ("Agreement") is made and entered into by and between Hobble Creek Behavioral Health ("Clinic") and the undersigned client or guardian ("Client"), effective as of the date of the last signature below.
1. Payment Options:
Self-Pay: Client agrees to pay for services rendered by the Clinic at the time of service. The Clinic will provide the Client with the necessary documentation to submit for reimbursement if the Client chooses to seek reimbursement from their insurance company.
Insurance: Client agrees to provide all necessary insurance information, including policy number, date of birth (DOB), street address, full legal name of the insured, and full legal name of the primary insured if different, to enable the Clinic to verify benefits with the insurance provider.
2. Verification of Benefits:
Upon receipt of the required insurance information, the Clinic will complete a verification of benefits (VOB) to determine coverage eligibility and benefits under the Client's insurance plan. This process is intended to provide an estimate of coverage but is not a guarantee of payment by the insurance company.
3. Client Responsibilities:
The Client is responsible for any charges not covered by insurance. This includes, but is not limited to, deductibles, co-pays, and any services not covered under the Client's insurance plan.
The Client agrees to inform the Clinic of any changes in insurance coverage or personal information that could affect billing or insurance claims.
4. Deductibles and Out-of-Pocket Maximums:
The Clinic will inform the Client if the insurance verification process indicates that the Client's deductible and/or out-of-pocket maximum have not been met. Payment for services rendered will be required until such deductibles or out-of-pocket expenses have been fulfilled according to the terms of the Client's insurance policy.
5. Payment Methods:
The Clinic accepts payment via cash, check, credit/debit cards, and other electronic payment methods approved by the Clinic.
6. Late Payments and Fees:
The Client agrees to pay a late fee for any payments not made at the time of service. Details of the late fee structure will be provided by the Clinic and are subject to change.
7. Cancellation Policy:
The Clinic maintains a cancellation policy requiring notice of cancellation at least 24 hours prior to the scheduled appointment. Failure to provide such notice may result in a cancellation fee charged to the Client.
8. Agreement to Pay:
By signing this Agreement, the Client acknowledges their understanding and agreement to comply with the terms and conditions outlined herein, including the responsibility to pay for services rendered by Hobble Creek Behavioral Health.

This Agreement is intended to ensure clear communication and understanding regarding payment and insurance processes at Hobble Creek Behavioral Health, supporting a transparent and efficient therapeutic relationship.

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Your Agreement of Financial Responsibility When Receiving Services at Hobble Creek Behavioral Health

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