Financial Agreement | Forms | Tracy Riley Counseling Jacksonville FL

As a courtesy to our patients, we accept assignment of benefits from most insurance companies. However, we do require you to pay your deductible and/or estimated patient portion at the time of service. Our fees reflect what is usual and customary for our area, as well as the quality of treatment that you receive.

Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. Any and all fees quoted for treatment are based on the current information provided to us by your insurance carrier.

Initial each line as you read it, and provide your signature and printed name at the bottom of the form.

Initial*

I understand that I am responsible for the fees for the services that are rendered by Tracy Riley Counseling. I understand that payment is due when services are rendered unless other arrangements are made in writing.

Initial*

I understand that there is an administrative fee of $38.00 for all returned checks in addition to any other fees assessed by corresponding financial institutions.

Initial*

I understand that I will be charged for the full reimbursement rate should I fail to appear for an appointment or if I fail to cancel within 24 hours of notice. This policy is thoroughly explained in the Cancellation Policy Form, and I agree to pay the fee of $95.00.

Initial*

I understand that if I am using my insurance or EAP, Tracy Riley Counseling will bill them directly. As long as I am using “in network” benefits, my responsibility is limited to my co-pay/co-insurance/deductible amounts. If I am using “out of network” benefits, I may be responsible for additional costs. I understand that only one authorization with my EAP will be accepted.

Initial*

I understand that if my credit card is declined, that I remain responsible for the charges owed. I understand that Tracy Riley Counseling will make every effort to collect the charges owed, up to and including utilizing a third-party collection agency, and reporting negatively on my credit bureau file.

Signature*

Reset

Signature/Print Name (Legal guardian signs for minor under the age of 18)

Date*

Updated 12/01/2023.