Adult Payment Form






    Telephone Number(s):




    Okay to leave voicemail at work?
    Yes
    No

    Home?
    Yes
    No

    Cell?
    Yes
    No

    Okay to text cell?
    Yes
    No


    Ok to communicate by email?
    Yes
    No





    FORM OF PAYMENT

    Self-pay
    Yes
    No

    Medicaid?
    Yes
    No

    Medicare?
    Yes
    No

    In Network Insurance?
    Yes
    No

    Out of Network Insurance?
    Yes
    No


    INSURANCE, MEDICAID AND/OR MEDICARE INFORMATION













    *Please bring to your appointment a current driver’s license and Insurance, Medicare and/or Medicaid card.*

    Martial Status:
    Single
    Engaged
    Married
    Divorced
    Separated
    Widowed







    OTHER FORMS OF PAYMENT (EAP, CHURCH, ETC.)
    If a 3rd party other than insurance is going to be involved in paying the client’s charges, please complete the following:





    FEES

    The charge for the 1st session is $200.00 (Two hundred dollars). The following 45 minute sessions charge is $175.00
    per session (One hundred seventy – five dollars). Payment is due at time of service. Payment is by credit, debit,
    HSA, FSA only for TeleMental Health sessions utilizing the HIPAA compliant Ivy Pay service. In person sessions
    can also be paid by check or cash. Please also be aware the return check fee is $50.00. Note different fees apply for
    records release and participation in client legal matters. See “Psychologist- Client Services Agreement”.
    I voluntarily choose and ask that my typed name on the signature line(s) of this document
    legally represent my electronic signature.

    Assignment of Benefits

    BreakThru Counseling & Consulting, P.C. (“BCC”)’s policy is for payment to be made when services are rendered.
    If this is a problem or if prior arrangements have been made, please contact Dr. Warner to discuss.
    In consideration of services provided to me by”BCC”, I hereby assign to BreakThru Counseling and Consulting,
    P.C. all insurance benefits otherwise payable to me resulting from the care rendered by BreakThru Counseling and
    Consulting, P.C. and/or Dr. Quincy Warner and to make payment covered by this assignment directly to “BCC”. I
    understand and agree that BreakThru Counseling and Consulting, P.C. may elect to accept or not accept such
    assignment. I further understand and agree that this assignment shall not be construed as relieving me from
    responsibility for any payment due and owing or which may become due and owing to BreakThru Counseling and
    Consulting, P.C. for services rendered to the client or from the obligation of remitting to BreakThru Counseling and
    Consulting, P.C. any insurance proceeds which I, as the client, may inadvertently be paid by any insurance company
    for claims arising out of treatment at “BCC”.



    Permission to Release Information

    I give my permission for BreakThru Counseling & Consulting, P.C. and/or Dr. Quincy L. Warner to release any
    information about me to my insurance company, any other 3rd party payer and/or “BCC”’s billing and collections
    firms and, if needed, to any courts and/or regulatory agency (ex. Georgia Office of Insurance and Safety Fire
    Commission) necessary to process any claims and/or regulatory review that result from services rendered to me by
    “BCC” and Dr. Quincy L. Warner. This release can be revoked at any time by informing “BCC”/Dr. Warner in
    writing, except to the extent that action has been taken in reliance upon it. Otherwise, it stays in effect until
    payment in full is received by BreakThru Counseling & Consulting, P.C.