Psychiatric Wellness and Dementia Care, LLC
Dr. Tatiana Sadak PhD.PMHNP.ARNP
(206)459-1158
Financial Agreement and Insurance Information
Name______Date of Birth ______Today’s Date______
Agreement to Pay:
· I understand that I am financially responsible to Psychiatric Wellness and Dementia Care, LLC for services rendered.
· I agree to pay the co-pay, coinsurance, and any deductibles stipulated by my insurance plan.
· Payment is due at the time of my appointment unless other arrangements have been made.
· It is my responsibility to inform Psychiatric Wellness and Dementia Care, LLC of any changes that affect the billing or charges to my account. This includes changes in any of my third-party payors, income or family status.
· I understand that standard collection procedures will be followed if payment is not made.
Initial for above statements ______
Standard fees and charges:
· Fees range based on the nature and the length of your appointments and on your insurance contract
· If we are contracted with your insurance, we will bill them directly
· If we are not contracted with your insurance you will have to pay in full at the time of your appointment and we will provide you with a receipt that you can submit to your insurance
· If you do not have insurance please enquire about out of pocket fee schedules
Out-of-pocket, Not covered by insurance
· Telemedicine (via video-conferences) same rates as above
· Phone call, email, texts, filling out forms, care coordination (communication with hospitals and clinicians...) fees, prorated based on $130/hr (may be reduced or waived in cases of financial need)
· $25 medication refill without scheduled appointment fee
· $25 fee for not paying co-pays or patient-portion of the bill at the time of service
· $130 late cancellation (must cancel 48 hrs prior to appointment) or no-show fee
Statement of Income (only fill out if applying for reduced out of pocket payments):
· In order to be considered for a fee adjustment I hereby certify that my weekly/monthly/annual gross family income is ______for a family size (include self) of ______.
· If I qualify for a fee adjustment, I agree to provide verification of income.
· I agree to pay an out of pocket fee
o $______for 30 min appointments
o $______for 60 min appointments
______
Client Signature Date
______
Staff Signature Date
Insurance Information
Primary insurance name ______ card on file
Insured’s Name ______Insured’s Date of Birth ______
Month / Day / Year
Insured’s Address ______Insured’s Phone Number______
______
City State Zip code
Insured’s Social Security #______Gender Male Female
Insured’s Policy #______
Insured’s Relationship to client Self Spouse Parent Other
Insured’s Employer______
Employer’s Address
______
City State Zip code
Secondary Insurance name: ______ card on file
Insured’s Name______Insured’s Date of Birth ______
Month /Day /Year
Insured’s Address______Insured’s phone number______
______
City State Zip code
Insured’s Social Security #______Gender Male Female
Insured’s Policy #______
Insured’s Relationship to client Self Spouse Parent Other
Insured’s Employer______
Employer’s Address______
I understand that having health insurance is not a guarantee that my condition is covered and that insurance payment will be made.
Assignment of Benefits: I authorize payment by my third-party payor (Insurance Company, Medicare/Medicaid, County, or other) to be paid directly to Psychiatric Wellness and Dementia Care, LLC for services rendered. I understand that I am financially responsible for charges applied to deductibles and for all charges limited by my third-party payor.
______
Signature of Individual Receiving Services/Legally Responsible Person Date
______
Staff Signature Date
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