Payment Agreement

In an effort to pay our providers in a timely fashion we are asking you to provide Transformations with a credit, debit or health savings account card prior to your service.  Our staff will ask for the card number prior to your initial session and enter the number into a secure encrypted credit card billing system.  If Transformations is billing your insurance company on your behalf, we will wait until we receive a response from the insurance company.  At that time we will bill your card for any remaining copay, coinsurance, deductibles or out of network charges.  Your Insurance company will mail you the same explanation for payment that they send to us. If you are paying for your services without insurance or have a pre-determined copay, Transformations may charge your card at the time of the service or in the weeks following.  

 

 

Payment Agreement

Client Name(Required)
MM slash DD slash YYYY
I understand that I am responsible to pay for services provided by Transformations staff and agree to pay Transformations for the cost of services rendered.

I understand that amounts not covered by my insurance company are my responsibility and I agree to pay for any charges not covered by my insurance plan. This includes but is not limited to co-pays, co-insurance, deductibles, denials, out-of-network denials, private pay agreements and all non-covered services.

I understand that if my private insurance coverage is cancelled or refuses to pay for services for any reason that Transformations may charge the card provided for the amount due.

I understand that it is my responsibility to contact my insurance plan and know the limits of my coverage. I do not hold Transformations accountable for any inaccurate information provided to he agency by the insurance company. Insurance companies do not guarantee accuracy of the information or payment when providing information to a provider.

I understand that Transformations does not practice balance billing. If we are surprised to discover that our provider is not in-network with your plan, Transformations will honor the contracted rate we maintain with your insurance plan.

I understand and agree to provide Transformations with an active credit, debit, or health savings card and to keep the agency updated on any changes or replacement cards.

I give permission to Transformations to submit a charge to any card I provide to the agency and to bill for charges incurred. The card may be billed at the time of the session or afterward once the agency receives a claim response and/or payment notice from the insurance company.

I understand that failure to provide an active card may result in a disruption of services.

Name(Required)
MM slash DD slash YYYY