Official Financial Policy and Billing Agreement Billing Agreement Please enable JavaScript in your browser to complete this form.Name (Print):Insurance Coverage:Clients agree to contact the Insurance Company to verify benefits for services rendered. You pay for your insurance. It is your responsibility to know the benefits of your policy(Initial)Should a dispute arise on a claim, it is generally the clients’ responsibility to clarify and dissolve the dispute with the insurance company(Initial)If Insurance is being filed, any deductible not yet met is due at the time of service well as any co-pay(Initial)Payment:Payment is expected at the time of service unless other arrangements have been made(Initial)I agree to provide a 24-hour notice to cancel an appointment. Otherwise, no show or late cancel charge will be assessed(Initial)If the client does not show up for a scheduled appointment, there is no show charge of $50 (Initial)Services requested by the client, but not covered by the client’s Insurance Plan may be arranged under a separate written agreement with the provider(Initial)Phone calls are not billable to your insurance. Phone calls over 10 minutes are billed for the amount of time spent on the phone, at the pro-rated hourly rate(Initial)Emails – no appointments will be scheduled via email. Phone calls will be responded to within 72 hours. Appointments will only be made via phone calls(Initial)Our self-pay fees are subject to change at the discretion of the practice. A list of self-pay services and fees is available upon request(Initial)There is a $30.00 administration charge for checks that do not clear the bank . . . . . . . . . (Initial)Questions regarding your account should be directed to the Billing service at 402-590-2947(Initial)I certify that I have read, understand, and agree to the foregoing. The undersigned is the client or is duly authorized by and on behalf of the client to execute the above and accept its term.Signature of ClientDateSignature of Witness DateSubmit
