Financial Agreement

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.

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.

Insurance Coverage

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

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. 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.

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

• Monthly statements: Each month, patients will receive a billing statement indicating any balance remaining after insurance payments.
• Copayments: Copayments are due at the time of service.
• Self-pay patients: Patients without insurance coverage are required to pay their balance at the time of their office visit.

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 $50 no-call/no-show fee. I acknowledge that insurance does not cover uncancelled appointments or associated expenses.

Updating Information

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

Attendance

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

Pre-Authorization for Health Services

I understand that many 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 to 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 may receive only crisis care until payment is made or a payment plan is established.

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.