Payment and Cancellation Policies

Payment and Cancellation Policies

GUARANTEE OF PAYMENT AND ASSIGNMENT OF INSURANCE BENEFITS:


The client of Bridge of Balance Wellness Center, Kim Finnie LCSW LLC, and JDF Wellness LLC promises to pay
. all charges incurred for services rendered to the client. The client understands that office staff will attempt to verify your mental health benefits, however, the office is not responsible for inaccurate information provided by your insurance company. It is, however, understood and agreed that the client is responsible for all monies due and owing for services rendered by the clinician in the event insurance does not pay for these services.Your client payment responsibility is expected at the time of your services. The office will file the client’s initial insurance claim(s) and provide documentation necessary for insurance reimbursement. The office does not, however, guarantee that each service will be covered or what percentage will be covered. There may be instances where the client will need to follow up with their insurance company in regards to any specific claim in question in order to rectify the lack of payment to the clinician. The client may incur extra charges for re-filing of insurance claims. It is requested that the balance owed will be rectified within 30 business days or a late fee of $15.00 will be added for each month the balance is not rectified.

CANCELLATION POLICY

A minimum of 48 hours notice is required for all new and returning appointments. Credit card information to be kept on file, including expiration date, CVR code, and billing zip code is required. Signing this form is an acknowledgment that you agree to be charged on this card in the event of a late cancellation or no-show. No-show fee is $65. Two consecutive no-shows/late cancellations will result in a $90 fee.

Credit Card #

Name on card

Expiration Date

CVV Code

Zip code of billing address

Insurance will not be billed for missed/canceled appointments.

Your signature indicates that you have read the above and agree to the terms contained therein.

Client Signature:
Date:

**All fields must be completed in order to successfully submit this form