Payment Policy and Consent for Patient

Financial Policy Waiver/Policy:

At Psychvisit, we are committed to providing you with the best psychiatric care possible. To ensure clarity and mutual understanding regarding payment for services rendered, we have outlined our payment policy below. By signing this document, you acknowledge that you have read and agree to adhere to these policies.

  1. Insurance Coverage Verification: We strongly recommend contacting your insurance provider prior to your appointment to verify coverage and ensure that Psychvisit and its clinicians are in-network providers. This helps to avoid any issues related to reimbursement or coverage.

  2. Insurance Claims and Payments:

    • We will file insurance claims with your primary insurance provider on your behalf.

    • Co-payments and deductibles are due at the time services are rendered. Any remaining balance not covered by insurance is expected to be paid within 60 days of the date of service.

    • Accepted forms of payment for co-payments include Cash, Money Order, and all Major Credit Cards. Personal checks are not accepted.

  3. Insurance Contractual Agreements:

    • Our participation with your insurance plan obligates us to charge only the fees allowed by your insurance company. Any difference between our fees and what your insurance allows will be adjusted accordingly.

    • Some services may not be covered by your insurance plan, and any non-covered services will be your responsibility to pay.

  4. Financial Responsibility:

    • All charges incurred for services rendered are the patient's responsibility from the date of service.

    • In the event of temporary financial difficulties, we encourage patients to promptly contact us for assistance in managing their accounts.

  5. Additional Fees:

    • A fee of $25 will be charged for the writing of medical letters.

    • A fee of $50 will be charged for missed appointments (no-show fees).

    • A fee of $25 will be charged for direct calls made after hours to speak with a provider.

  6. Collections and Legal Action:

    • In the event that an account is turned over to a collection agency or attorney, the patient will be responsible for any associated fees and charges.

    • A 10% service charge (Minimum of $15) will be added to the balance if the account is sent to a third party for collection.

    • The patient will be responsible for all litigation expenses, court costs, and reasonable attorney's fees incurred in the collection process.

Assignment of Insurance Benefits & Acceptance of Financial Responsibility: I authorize the direct payment of any medical benefits to Psychvisit for services rendered. I understand that I am responsible for any charges not covered by insurance. In the event of account collection, I agree to pay all associated fees and expenses.

Revised-4/13/2024 Faisal Rafiq MD.