Appointment and Billing Information
1. I would appreciate at least 24 hours notice if you will not be keeping your scheduled appointment. Other clients will appreciate your courtesy in releasing this time for them.
2. Individual appointments which are not kept or cancelled within the prescribed period will be billed at the usual rate, $120.00 for a 50 minute session, $160.00 for an initial evaluation. Insurance companies will not reimburse for a missed appointment. The patient is responsible for this bill.
3. Payment will be appreciated at the end of each office visit.
4. Any returned checks must be replaced for the amount of the check plus a $20 service charge.
5. Many health insurance policies require an individual or family to pay a specified deductible before they begin reimbursements. The patient is responsible for this deductible amount.
6. Many health insurance companies change reimbursement policies or patients mistakenly believe they will be reimbursed at a rate higher than the policy will allow. It is your responsibility to determine your type and extent of health insurance coverage, and you will be responsible for all balances following claim settlement by your insurance company.
7. I authorize the release of all medical information necessary to process claims, including by electronic means if available.
8. I authorize payment of medical benefits to Susan Bieber, Ph.D.
Please feel free to ask if you have any questions regarding any of the above policies. Your cooperation is greatly appreciated.
Thank you!
I have read the above and agree to abide by the conditions stated therein.
____________________________________________ ___________________________
Signature Date
2. Individual appointments which are not kept or cancelled within the prescribed period will be billed at the usual rate, $120.00 for a 50 minute session, $160.00 for an initial evaluation. Insurance companies will not reimburse for a missed appointment. The patient is responsible for this bill.
3. Payment will be appreciated at the end of each office visit.
4. Any returned checks must be replaced for the amount of the check plus a $20 service charge.
5. Many health insurance policies require an individual or family to pay a specified deductible before they begin reimbursements. The patient is responsible for this deductible amount.
6. Many health insurance companies change reimbursement policies or patients mistakenly believe they will be reimbursed at a rate higher than the policy will allow. It is your responsibility to determine your type and extent of health insurance coverage, and you will be responsible for all balances following claim settlement by your insurance company.
7. I authorize the release of all medical information necessary to process claims, including by electronic means if available.
8. I authorize payment of medical benefits to Susan Bieber, Ph.D.
Please feel free to ask if you have any questions regarding any of the above policies. Your cooperation is greatly appreciated.
Thank you!
I have read the above and agree to abide by the conditions stated therein.
____________________________________________ ___________________________
Signature Date