PLEASE PROVIDE A COPY OF THE INSURANCE CARD
INSURANCE BILLING POLICY
Carey Counseling is authorized to use a third party contractor to submit insurance claims, release client’s personal information to the insurance company, and authorize the direct payment to the provider. I understand that I am responsible for any deductible, co-pay, co-insurance or any other balance unpaid by the insurance that day and time the service is provided. I authorize use of this form on all of my insurance submissions.
All balances that day and time of services. Failure to cancel 24 hours prior to an appointment or a no call no show will be an $85.00 fee. All deductible/copays will be collected at each session via IVY PAY/cash. A credit card is required to be on file and will be billed at the time of service unless another method of payment is used. I authorize Carey Counseling to collect payment via IVY PAY at the time of services. Failure to comply could lead to termination.
There will be a $25.00 service charge on all returned checks. In the event that your account goes to collections, there will be a 35% collection fee added to your balance.
Please review the privacy policy and sign that it was received.
