FINANCIAL POLICY

Serene Minds Behavioral Health Financial Policy

Thank you for choosing Serene Minds Behavioral Heath for your psychiatric care. We appreciate that you have entrusted us with your health care, and we are committed to providing you with the best patient care possible. Due to complexity involved in healthcare benefits and coverage options, we have developed this financial policy to help you better understand your rights and responsibilities as a patient.

1. We will collect your deductible, co-pay, uncovered services, past due balance, or the percent you are responsible for at the time of your visit. Please be prepared to pay at the time of your visit. Failure to pay will result in a cancellation of your appointment.
2. We will bill your insurance for covered services. It is your responsibility to make sure we receive prompt payment from them. It is useful to maintain frequent contact with your insurance carrier to make sure they are paying as they should. Once they have paid, you will receive a bill for any remaining deductible or co-insurance amounts owed. The balance is due in full within 30 days of receipt of the statement. Failure to pay within 30 days will result in inability to schedule any further appointments at our office. If you are unable to pay the full amount within 30 days, please call our office to create a payment plan and avoid referral to an outside collection agency.
3. Your health insurance policy is a contract between you and your health insurance company. Please note it is your responsibility as the Policy holder/Patient to understand the coverage and benefits and be knowledgeable of any deductibles, copayments and/or coinsurance. It is your responsibility to be sure that our office is in-network and the services are covered under your plan. If our office is out-of- network, you will have a higher out of pocket cost. If you have any questions in regards to your current insurance policy benefits you should contact your insurance plans’ Member Services. Do not hesitate to contact them if you disagree with their payment or to find out the status of your claims.
4. You must provide your current insurance card and any authorization information you may have at each visit or when you schedule your appointment. We must be able to verify your eligibility prior to your visit or your appointment will be re-scheduled. In addition, failure to inform us of a change in insurance may result in exceeding the limits of the time allowed to file a claim and you will be responsible for all charges. We will scan a copy of your insurance card and photo ID to copy and keep on file for our records in accordance with insurance plan requirements.
5. If your insurance company denies payment on your account, you will be required to pay the balance. You will be responsible for any and all charges not paid or discounted by your insurance.
6. SELF-PAY PATIENTS: This category includes patients with no insurance and the patients who have an insurance plan with which we do not participate or choose not to use their insurance. Payment for medical services is required prior to services being rendered. We accept major credit cards and debit cards and Zelle. We will provide you with a receipt.
7. It is important that we have your correct address and telephone information on file. Please advise us anytime there is any change to your address, telephone, email address, or other contact information. Failure to update our office of any changes to your contact information will not delay the billing process for any patient balances on your account.
8. NON-MEDICAL FEES: Occasionally, there are costs that insurance will not cover; you are responsible for these costs. For example: We charge $75 for no-shows and late cancellations.
9. We understand that every person’s financial situation is unique. If you are having trouble paying your bills, please know that we are willing to work with you to create a payment plan that is fair to both you and Serene Minds Behavioral Health LLC.

Fees:

Cash Pay:

Initial Evaluation:

• New pt evaluation 60 minutes – $185

Medication management

• Established pt 20-30 min session f/u – $85
• Medication and psychotherapy 30 min f/u – $ 100

Psychotherapy

• Established Individual session 30 f/u -$85
• Established Individual session 45min – 100

PRESCRIPTION & MEDICATION POLICY

• Our providers prescribe sufficient medication to last until the next visit.
• It is your responsibility to schedule an appointment before you run out of medication.
• It is very important to request your prescriptions during your office visit. Incase this is not possible, please notify your provider at least 3 working days before you run-out of medications.
• WE DO NOT REPLACE LOST PRESCRIPTIONS FOR CONTROLLED SUBSTANCES.
• It is your responsibility to notify our office if you recently changed pharmacy.
• We will continue to take the time to carefully review your medications and write refills during your office visit. We will also review the prescriptions with you to make sure that they are written correctly and sent to the correct pharmacy.
• We will only authorized refills can on medication prescribed by our provider. We will not refill medications prescribed by other providers.
• New symptoms or events require an appointment. Please schedule an appointment if this occurs.
• Questions regarding medications, please discuss these during your appointment. If for any reason you feel your medication needs to be adjusted or changed, please contact us immediately.

Sometimes your insurance company will not pay for the medications that your providers prescribe. When this happens, you have three options:

1. Your insurance company has a list of medicines that they will cover. This list is called a formulary. We can try to identify equally safe and effective, but cheaper formulary alternatives to any high-cost medicines we prescribe.
2. We can send the prescription to a specialty pharmacy that will work with your insurance company to get the medicine approved via prior authorization.
3. You can pay out of pocket for the medicine at your preferred pharmacy.

Patient medication history is a list of prescriptions that healthcare providers have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history.

The collected information is stored in the practice electronic medical record system and becomes part of your personal medical record. Medication history is very important in helping providers treat your symptoms and/or illness properly and avoid potentially dangerous drug interactions.

It is very important that you and your provider discuss all your medications including OVER-THE-COUNTER DRUGS, SUPPLEMENTS OR HERBAL REMEDIES in order to ensure that your recorded medication history is 100% accurate.

I understand that my healthcare provider will obtain my medication history from my pharmacy, my health plans, and my other healthcare providers.

Patient Name:  

Patient or Guardian Signature: