FINANCIAL POLICY

Text Box: HARDY HEALTHCARE ASSOCIATES IS NO LONGER ACCEPTING INSURANCE.  ALL PAYMENTS WILL BE EXPECTED AT TIME OF SERVICE.  WE WILL ASSIST YOU BY SUPPLYING YOU WITH INVOICES TO SUBMIT FOR REIMBURSMENT FROM YOUR INSURANCE COMPANY.  

 

 

 

 

 

CANCELLATION POLICY:

 1) New Evaluations:  we require 14 days notice for cancelled, and 7 days notice for rescheduled, evaluations because of the amount of time reserved for this appointment.  Failure to do so will cause a forfeit of your $250 deposit.  Please note that there is a $50 non-refundable administrative fee for all cancelled initial evaluations.

 2) Follow-up Appointments: cancellations must be made by 9 AM of the business day prior to the scheduled appointment (this means Friday for a Monday appointment).  This is because we do not overbook in anticipation of a cancellation or ‘no-show’.  The time scheduled is for you and cannot be used by anyone else without advance notification.  Therefore, in the case of a late cancellation the fee will be $50, and for a no show you will be charged $100. This charge must be paid on or before the next visit.  We very much prefer to avoid this unfortunate circumstance and hope that it can be avoided completely.  We shall respect your time and schedule and we hope that you will be respectful of ours. 

 

*I have read the above cancellation policies and understand them fully.  INITIAL PLEASE _________.

 

OFFICE FEES: New patient evaluation fees are based on $500/per hour; follow-up appointments are $350/per hour.  Your fee will be determined by the amount of time used.

 

TELE-CONFERENCES:  Tele-conferences are offered as a convenience to the patient and/or family where distance or transportation is an issue.  You may elect to schedule office visits instead.  Tele-conference time will be billed at the hourly rate of $350/per hour in tenth of an hour increments.  Please be aware that most insurance companies will not reimburse for teleconference services. The guarantor / patient will be responsible for this fee.  Tele-conference fees must be paid by credit card at the time of service.

 

*I understand that my insurance will not provide reimbursement for teleconferences, and that I will be responsible for this charge.        INITIAL PLEASE __________.                                                                                                          

 

ALL BALANCES OVER 30 DAYS:  Will be subject to monthly late charges (1.5% / month annually).

BALANCES OVER 60 DAYS:  Must be paid in full at least 48 hours prior to the next scheduled appointment.  RETURNED CHECKS:  There is a $25 service fee for any checks returned from your bank.

Text Box: THE FOLLOWING AUTHORIZATION IS REQUIRED FOR ALL PATIENTS / GUARANTORS AT HARDY HEALTHCARE ASSOCIATES.  YOUR COOPERATION WITH THIS POLICY IS APPRECIATED.  

 

 

 

 

 

 

 

CREDIT CARDS: I authorize the use of my credit card for direct payment for teleconferences and/or any other balance not covered by my insurance. VISA OR MASTERCARD ONLY.

 

________________________________________    ________     ______________________          

Credit Card Number                                                   Exp Date                Signature

 

I have read and fully understand and accept the financial policy of Hardy Healthcare Associates

 

Signature: _________________________________________________       Date:________________

                         Patient or Parent/Guardian

 

Revised: JANUARY 2008