Assignment of Benefits / Financial Responsibility

I acknowledge the payment and insurance information set form below and agree to pay for services rendered to me and/or facilitate the payment for services rendered to me by the providers affiliated with New York Medical Behavioral Health Services, P.C. (Practice)

  1. Payment of Fees: I agree to pay for charges for services as described in this agreement. I understand that:
    • Payment for sessions with providers affiliated with Practice is payable online through debit or credit card or ACH transfer, unless otherwise established
    • Payment for sessions is due after each session unless otherwise agreed upon and Practice will charge my card or bank account for my responsibility. Receipts may be provided at the time of the charge or monthly
    • I will be charged for sessions that I do not keep, unless I provide enough notice to the provider affiliated with the Practice (your treating provider will tell you how much notice is required to avoid being charged for sessions you do not keep)
    • I understand that I cannot submit bills for cancellations to my insurance company or managed care plan
  2. Insurance and Managed Care Plans:

    Practice participates in a number of insurance and managed care plans. If Practice participates in my plan, I agree to pay all applicable deductibles, co-payments, co-insurances and any other form of cost-sharing. If my insurance benefits run out, Practice will inform me of the ending date, and I will then be responsible for all charges dating from the end of insurance coverage. If my insurance plan denies the visit despite Practice following necessary procedures, I understand I may be responsible to pay in full for the service.

  3. Assignment of Insurance Fees; Release of confidentiality for authorization of benefits and for clinical care:

    I agree to allow my insurance plan or managed care plan to pay Practice directly, instead of paying me. In the event that my plan pays me directly, I will promptly turn the payment over to Practice unless I have already paid the charges myself. I authorize Practice to provide my insurance plan or managed care plan any information reasonably required to obtain insurance benefits and authorization for services. I authorize Practice to obtain at any time during my treatment here, any and all relevant clinical information from clinicians and facilities that have treated me and to furnish relevant clinical information to providers who will continue to treat me. I will indicate in writing any exceptions to this.

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