We appreciate the opportunity to serve as your Behavioral Healthcare provider. We are committed to providing you with quality and affordable care. Please take a moment to review and sign this policy, ask questions as necessary.  A copy will be provided to each patient upon request.

Insurance: We accept assignment and participate in most insurance plans.  If your insurance is not a plan we participate in, payment in full is expected at each visit.  Knowing your insurance benefits is your responsibility.  Please contact your insurer with any question you may have regarding your coverage to receive the maximum benefit.

Patient Payment:  All copayments and deductibles are to be paid at the time of service.  Any outstanding balances must be paid prior to service delivery.  This arrangement is part of your contract with your insurance company.   Payment will be accepted in the form of cash, check, or credit card. There will be a $35.00 administrative fee for all checks returned for insufficient funds.

Forms:  Miscellaneous service fees not covered by insurance must be paid at time of request.

Registration: All patients must complete our patient information form, which will be entered into our computer to maintain accurate information for proper billing.  We must obtain a copy of your driver’s license and current valid insurance card to provide proof of insurance.  If you fail to provide us with the correct insurance information or your information changes and you fail to notify us in a time manner, you may be responsible for the balance of a claim.  Most insurance companies have time filing restrictions; if a claim is not received within 30 days of the date of service it can be rendered ineligible for payment and you will be responsible for the balance that remains..

Claims submission: We will submit claims for payment to your insurance company on your behalf. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

Private-Pay: If you choose to pay for your treatment directly rather than using your private health insurance; OR if you do not have health insurance coverage of any kind you will be fully responsible for all services rendered and all services will be payable and due prior to service delivery.

Credit and collections:  If payment from your insurance company is not received within 45 days of the date of claim submission, you will be expected to pay the balance in full.  Partial payments will not be accepted.  Any account balance that remains unpaid may be referred to a collection agency. If an account is sent to collections, it is the policy of this clinic to discharge the patient and possibly immediate family members from the practice.  You will at that time be notified by regular and certified mail that you will have 30 days to find alternative behavioral health care.  During that 30-day period our providers will be able to treat you only on an emergency basis.

Missed or Cancelled Appointments: You will be charged $35 for appointments missed and/or not cancelled within 24 hours of appointment time. This charge will be billed directly to you. Self-Pay and 3rd Party Beneficiaries Only

Our clinic is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. Please let us know if you have any questions.

I have read, understand and agree, to the terms and conditions as set forth in this policy.


Fees Not Covered by Insurance

Thank you for choosing CenterCare Health and Wellness.  Every effort will be made to give you the highest quality and most compassionate care possible.  Please note that your provider may see up to 100 patients a week during office hours, and answers many telephone calls regarding patient needs, including filling prescriptions if your provider is a nurse practitioner or psychiatrist.  Therefore, a fee will be charged for all additional work requested on your behalf and payment is required prior to completing paperwork.


Fees and Services


Letters – $50.00

Medical Records – $1.18 per page

Lost/Rewritten Prescriptions – $15.00

Prescriptions for Missed Appointments – $15.00

Returned Check Fee – $35.00

Forms Needing Providers Signature – $50.00


Fees Related to Legal Matters


Letters – $50.00

Review of Records – $150.00 hr./$50.00 minimum

Deposition – $250.00 hr. /door to door

On Call Testimonies via court or telephone – $150.00

Regarding requests for paperwork, please note that your provider may take up to 15 business days to complete paperwork.  You are responsible for all service fees incurred.  Fees for services are payable to The Center for Health Care Services.  Unless otherwise agreed upon, you are responsible for all fees incurred.  I have read, understand and agree, to the terms and conditions as set forth in this policy.