Financial Policy Financial Policy Please enable JavaScript in your browser to complete this form.Knowing your insurance benefits is your responsibility. All patients must complete our patient information form before seeing a provider and provide proof of insurance with a copy of a current valid insurance card(s). If you are covered by more than one insurance plan it is your responsibility to coordinate your benefits and provide the office with all insurance information. We participate in most of the major insurance plans. If you are not insured by a plan in which we participate, payment in full is expected at each visit. Most insurance policies provide some coverage for mental health treatment. It is very important that you find out exactly what mental health services your policy covers, including the maximum number of visits allowed per year. If you have questions about the coverage, contact your plan’s Member Services. All co-payments must be paid at the time of service. This arrangement is part of your contract with your insurance company and we will collect payment based on the information on your insurance card. For many policies, the co-pay may change during your course of treatment and insurance plans change co-pay rates without notifying providers. If your co-pay was higher than collected, you are responsible for paying the difference. If it should have been lower, we will give you a refund or credit. Claims submission. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract. As a courtesy to you, we will submit claims to insurance companies with which we participate and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, please be aware that the balance of your claim, which may include deductibles, is your responsibility whether or not your insurance company pays the claim. Coverage changes. If your insurance changes, please notify us before your next visit so that we can make the appropriate changes to help you receive your maximum benefits. If you fail to notify us of insurance changes in a timely fashion, you may be responsible for your entire bill. Missed appointments. We require 48 hour notice if you need to cancel an appointment. You may be charged for any missed appointment or cancelled appointment (when 48 hour notice was not given). These charges will be your responsibility (insurance companies do not provide reimbursement for cancelled sessions) and billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointment or by calling 48 hours prior to your appointment. Invoices. Electronic statements are sent out at the beginning of each month and paper statements are mailed every other month. After claims are processed, balances that are your responsibility will be billed to you and are payable upon receipt. In the event of self-pay balances over 60 days past due, Newton-Wellesley Psychiatry will add a service charge of 1.5% of the outstanding balance, or a minimum of $5.00, with each 30-day billing cycle. Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns. Acknowledgement *I acknowledge that I have received and understood the contents and purpose of the document described above. I understand that it is my responsibility to read and follow the policies.Patient's Signature * Clear Signature Today's Date *Patient's Name *Patient's Date of Birth *Signature of Legal Representative (If patient is unable to sign) * Clear Signature Today's Date *Legal Representative Name *Relationship of Legal Representative to Patient: *Acknowledge