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.