Austin Psychiatric Alliance - Financial Policy

Thank you for choosing Austin Psychiatric Alliance as your mental-health provider.  We are committed to providing the best medical care possible.  

Please understand that payment of your bill is considered a part of your treatment.  

The following statement explains our Financial Policy, which we ask you to read, sign, and return to us.  You will also be provided with a copy of this policy.

Ÿ  All patients should provide accurate and complete personal and insurance information prior to being seen by the doctor.

Ÿ  All applicable co-pays and personal balances (both current and prior) are due at the time of service.

Ÿ  We accept cash, personal checks, money orders, Visa, Master, and Discover card.

Regarding Insurance

We participate in a number of insurance plans.  For some insurance a deductible may apply, and this is paid by the patient.  

While we try to affiliate with as many plans as possible, changes can occur, so please verify any insurance changes each time you visit.  

In ALL cases we require that the guarantor (the person who is financially responsible) be personally liable for all balances not covered by insurance.  

It is your responsibility to understand and comply with any predetermination of benefits or referral requirements.  Please be advised that some, and perhaps all, of the 

services provided may be non-covered services or may not be considered medically necessary under the Medicare Program or by other medical insurance companies.

Usual and Customary Rates

We are committed to providing the best treatment for our patients and we charge what we believe to be reasonable and customary fees for our region and specialty.  

While we usually accept insurance assignments of benefits, you may be responsible for any remaining 

balance if your insurance company uses a different fee schedule, .

Co-Pay Balances

Payment of co-pays is expected at the time of service.  If you are unable to pay your co-pay at the time of service, you may be required to reschedule your appointment.  

Under special circumstances an appointment may be accepted without payment of the co-pay.  In those cases, the co-pay will be added to your account balance 

and must be paid at your next visit.  Co-pays are, under all circumstances, the patient's responsibility.

Missed Appointments

Please help us to serve you better by keeping scheduled appointments. If you have to miss an appointment, please provide us with more than 24 hours notice.  

If this is not possible, notify us as soon as possible.  Missing an appointment without notice will result in a $35 charge being added to your account balance.  

This fee is not covered by insurance and will be due at your next appointment.

Returned Checks

Each check returned to us as unpaid by your bank will be charged a $35 fee.  The fee will be added to your account balance, and your full account balance will be due in cash 

at your next visit.  This fee is not covered by insurance.

Past Due Accounts

We value you as a patient, and we will work with you to resolve any past due amounts.  Past due accounts will be sent three requests for payment.  

If you are unable to pay your balance in full, please let us know so that we can arrange a payment plan with you.  Failure to respond to these requests 

or to arrange to pay any past due amount will result in your account being referred to a third party for collection.  This may also result in a suspension of services 

except on an emergency basis.

Miscellaneous Fees

We reserve the right to charge fees for miscellaneous services including, but not limited to, after hours refill requests, copies of medical records, refills requiring triplicate prescription forms, or other services.  

You will be notified the amount of the fee before the service is rendered with the option to refuse the service.  Fees accrued will be added to your account balance and will be due at your next appointment.  

Generally, these fees are not covered by insurance and will be your responsibility. Any questions or concerns about this policy or your account should be addressed to our office staff in person or by telephone.

Signature of Acknowledgment

I have read the Financial Policy.  Further, I understand and agree to the Financial Policy.  This policy supercedes any previous Financial Policy, and constitutes a part of my treatment.

Signature                                                                                                                                          Date