Adult Payment Form Client Name Address City State Zip Telephone Number(s): Home Office Cell Okay to leave voicemail at work? Yes No Home? Yes No Cell? Yes No Okay to text cell? Yes No Email Ok to communicate by email? Yes No Date of Birth Age Employer Relation to Insured FORM OF PAYMENT Self-pay Yes No Medicare? Yes No In Network Insurance? Yes No Out of Network Insurance? Yes No Other INSURANCE AND/OR MEDICARE INFORMATION Insured's Name Insured's Employer Ins. Effective Date Insurance Company Policy or Group No Insurance Co. Address Benefits Phone # Precert Phone # Name of person responsible for payment Address (if different from address above) Do you have other insurance? If so which is primary? *Please bring to your appointment a current driver’s license and Insurance, and/or Medicare card.* Martial Status: Single Engaged Married Divorced Separated Widowed Name of Spouse Age Spouse's Occupation Place of Employment Spouses Work Phone # I heard about BreakThru Counseling and Consulting P.C. from: 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: Name of 3rd Party Payer Phone Address Additional Information 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 a HIPAA compliant payment platform. 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”. Signature of Client Date 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. Client Signature Date
