Agreement to Pay: Payment is due at the time service is provided. I agree to pay the established fee on each visit. I understand that I may be denied an appointment if I refuse to pay, when I have the ability to pay. It is my responsibility to inform PhoenixWay of any changes that affect my ability to pay. PhoenixWay currently accepts cash, check, credit cards, PayPal (firstname.lastname@example.org), and accepts most major forms of private medical insurance. Currently, PhoenixWay does not accept Medicaid or Medicare.
We may accept assignment of insurance benefits if we are contracted with your private insurance company. However, please understand:
--We file insurance as a courtesy and it is your responsibility to verify insurance benefits. All charges are your responsibility, whether your insurance company pays or not.
--If the private insurance company does not pay your balance in 45 days, we ask that you contact the carrier.
--If the private insurance company does not pay within 60 days, we ask that you pay the balance due.
Assignment of Benefits: I authorize and direct all private and public insurers who have responsibility for payment of services to directly pay PhoenixWay. I authorize and direct any person or corporation having notice of this assignment to directly pay PhoenixWay all medical, liability or other insurance or third party benefits. I understand that I am financially responsible to PhoenixWay for charges applied to the insurance deductible and for all charges not paid by the insurance company.
Release of Information for Payment: I authorize PhoenixWay to disclose any and all parts of my medical record and health information, which may include health information pertaining to psychiatric, drug and alcohol abuse conditions, AIDS, AIDS-related conditions, or HIV, only for the purpose of review and payment as required by private insurances / third party payers that are on file with PhoenixWay.
Cancellation Policy: I understand that if I cancel an appointment less than 24 hours before it is scheduled, I am liable for a cancellation fee of $40, unless an exception is requested and allowed. No-shows (without informing me) may be subject to the entire fee for the session.
We understand that temporary financial problems may affect timely payment of your balance. We encourage you to communicate any problems so that we can assist you in the management of your account.
By typing my full printed name and date in the boxes below, I hereby consent to the terms of this document.