Financial Agreement

I understand that Ken Starr MD Wellness Group is out of network for all other insurances at this time. As a courtesy per request, and with a signed release of information, they will attempt to get authorization for payment and bill my insurance for services rendered. I understand I am ultimately responsible for payment for all services rendered by Ken Starr MD Wellness Group, as insurance reimbursement cannot be guaranteed. If my insurance does not cover all or part of my care, I may request a ‘superbill’ to advocate directly to my insurance for payment reimbursement. If my insurance policy requires ‘prior authorization’ in order to receive services, an office staff will assist me in acquiring pre-authorization with the understanding that Ken Starr MD Wellness Group will not be held liable for future insurance claims of reimbursement. I understand I will receive a billing statement from Ken Starr MD Wellness Group reflecting any balance due on my account. I understand Ken Starr MD Wellness Group will not accept responsibility for collecting insurance claims or negotiating a settlement on a disputed claim. I understand that failure to pay Ken Starr MD Wellness Group may jeopardize my insurance benefits and ability to receive services. I understand that since I am the individual receiving services, I am financially liable. I acknowledge that fees within my Financial Agreement reflect cash rates billed to the patient; they may not reflect the true and actual cost of service reflective of industry standards and customary fees. I understand that the cost of insurance copays may exceed the cash price discount I pay; in such an event I will complete a financial waiver to resolve the difference. I understand that there is a 15% fee for handling and distributing insurance reimbursement payments. Reimbursement after insurance, if any, will be based upon the allowable amount listed on the Explanation of Benefits. I may choose to accept a ‘superbill’ and bill my insurance directly in order to avoid such fees; in this event I would be a ‘cash pay’ only client.

DELINQUENCY
I understand that Ken Starr MD Wellness Group will make several attempts to collect payment. I will be notified by telephone and letter once my account becomes delinquent after 30 days. I understand that if my account is more than 90 days in arrears and no attempt has been made on my part to return calls or set up a payment plan, my account will be terminated and sent to a collection agency. I understand that a re-billing fee of 5% in compliance with California state law will be applied to any overdue balance. In the event of non-payment, my bill will be subject to collections with an additional 20% fee in addition to court costs and reasonable legal fees.
 

LATE CANCELLATIONS
I understand that I must call to cancel an appointment 12 hours or more in advance. Cancellations with less than 12 hours notice will result in a $50.00 late cancellation fee. A no call no show will result in a fee equal to the cost of the missed appointment. If I have paid for a program package such as private pay IOP, a less than 12 hour cancellation will result in the service appointment being counted as ‘used’. I will not be allowed to recover a missed appointment if I did not follow the 12 hour cancellation requirement. I understand that if my credit card is on file, it will be used for payment of services scheduled that do not receive a 12 hour or more cancellation. I understand that my insurance policy will not cover the missed appointment fee. Balances must be paid in full before scheduling future appointments.