Financial Agreement

Authorization and Responsibility:

I authorize Nebraska Peace of Mind Behavioral Health, LLC to release necessary medical information to insurance carriers for claims processing. I understand that I am responsible for obtaining any pre-authorizations required by my insurance and for all associated charges. Charges for office visits are determined by the complexity of the medical issues addressed and the clinical decision-making or the time spent by providers' to deliver safe treatment, in accordance with national coding guidelines.

Insurance Coverage:

I acknowledge that it is my responsibility to ensure that my insurance covers the services provided, including telehealth services.

Missing or undisclosed insurance coverage:

Patients are responsible for providing accurate and up-to-date insurance information at every visit. If a Medicaid patient has other primary insurance coverage and does not disclose it, or fails to complete the required Coordination of Benefits (COB) with Medicaid, resulting in a denial of the claim, the full balance will become the patient’s responsibility.

Accurate Insurance Information:

I understand that providing accurate and truthful insurance information is crucial. If I provide inaccurate or misleading insurance information, I will be responsible for the entire balance of the visit.

Credit card on file

A valid credit card is required to schedule and receive services. Your card will be used for co-pays, deductibles, no-show fees, late cancellation fees, and unpaid balances. Patients who refuse to keep a card on file may be denied future appointments. Medicaid patients are encouraged but not required to keep a card on file.

Billing Procedures:

  1. Statements: Patients will receive a billing statement indicating any balance remaining after insurance payments.

  2. Copayments: Copayments are due at the time of service.

  3. Self-Pay Patients: Patients without insurance coverage are required to pay their balance at the time they schedule their visit or before their office visit.

Refund Policy and Processing Fees

All payments made to Nebraska Peace of Mind Behavioral Health are subject to this Refund Policy.

If a refund is issued for any reason, including but not limited to overpayments, duplicate payments, appointment cancellations, insurance adjustments, patient-requested refunds, or account credits, the original payment processing fees incurred by the practice will not be refunded.

All refunds will be reduced by a non-refundable processing fee equal to 2.9% of the original transaction amount plus $0.30 per transaction. This amount reflects the merchant processing fees charged to the practice by third-party payment processors at the time the payment was made and is not retained by the practice as profit.

Refunds will be issued only after the account has been fully reconciled, including confirmation of insurance adjudication, claim finalization, and verification that no outstanding balances remain. Nebraska Peace of Mind Behavioral Health reserves the right to apply any credit balance toward outstanding or future services prior to issuing a refund.

Refunds will be issued to the original method of payment whenever possible. If the original payment method is unavailable, the practice reserves the right to issue a refund by check or alternative method at its discretion.

Refund processing may take up to 14 business days after eligibility for refund is confirmed. Banking institutions may require additional time for funds to post.

By signing this Financial Agreement, you acknowledge, understand, and expressly agree to this Refund Policy and authorize Nebraska Peace of Mind Behavioral Health to deduct applicable processing fees from any refund issued.

Patient Responsibilities:

As a patient, I understand and agree to the following responsibilities:

Appointment Cancellation:

I will cancel appointments at least 24 hours in advance to avoid a $100 no-call/no-show fee. I acknowledge that insurance does not cover uncancelled appointments or associated expenses.

  1. Updating Information: I will promptly inform the receptionist of any changes to my contact information or insurance carrier.

  2. Attendance: I will attend appointments as scheduled or as determined by myself and my service provider.

Pre-Authorization for Health Services:

I understand that most insurance companies require pre-authorization for health services, medications, and certain treatments. I am responsible for contacting my insurance provider to inquire about pre-authorization requirements and understand my health benefits.

Collections:

Unpaid accounts after 90 days may be sent to collection agencies. This action may result in additional fees for which I am financially responsible. Accounts with balances over $200.00 or 90 days overdue may receive only crisis care until payment is made or a payment plan is established.

Outstanding Balances & Payment Plans

Outstanding balances must be paid in full immediately or a payment plan must be approved through Cherry Financing before additional services are provided.

Nebraska Peace of Mind Behavioral Health no longer offers in-house payment plans. Patients with unpaid balances will be required to either:

Pay the balance in full, or

Apply for and receive approval through Cherry Financing.

If neither option is completed, future appointments may be canceled or limited to crisis care only until the balance is resolved

Cherry Financing allows patients to spread payments out over time and may offer 0% interest promotional options for qualified applicants. Patients may apply online through our website or request a secure application link from our office.

Late Arrival:

If I arrive late for an appointment, it may be canceled or rescheduled at the discretion of the clinic to ensure fair scheduling for all patients.

I have carefully reviewed the financial agreement policy for patients at Nebraska Peace of Mind Behavioral Health, LLC, and agree to comply with all its provisions by signing below.