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Financial Policy – STRIVE Series Thank you for your interest in the STRIVE to Succeed Series. We are committed to your weight loss journey being successful. The following is a statement of our Financial Policy, which we require that you read and sign prior to your first meeting. Please understand this financial policy is enforced to keep costs at a reasonable level, thus preventing fee increases. This also allows us to concentrate on what we do best: helping you with your weight loss journey!!

Payment Methods Accepted: ○ ○

We accept cash, checks, money order, MasterCard, VISA and American Express or HSA and FSA cards with the VISA logo. Payment is expected, in full, at the time of service, we do NOT accept post-dated payments. We reserve the right to refuse service if payment is not made at the time of service.

Insurance: ○



Nancy Lum does not participate with insurance companies. You will be provided with a nutrition medically coded receipt for weight loss upon completion of the series or once you have paid in full, whichever comes first. This nutrition coded receipt can be submitted to your insurer to seek reimbursement; we cannot guarantee you will be reimbursed. We do not accept Medicare Assignment. If you are unable to be reimbursed for our services please save the receipt for your tax and/or flex spending purposes. You may be eligible for reimbursement from your insurance company if you see therapist Dawn O’Meally for an individual assessment, no less than two weeks prior to the first class. See below for instructions on how to utilize your mental health benefits from your insurance company. INSURANCE:

If you have insurance coverage and plan to use your mental health benefits, for the costs of group therapy, you will need to be individually assessed by Dawn O'Meally LCSW-C, P.A. Insurance companies will not offer reimbursement without a proper diagnostic code(s). In order for Dawn O’Meally to bill your insurance, you must be individually assessed to obtain a diagnosis code for her to bill under. It is your responsibility to find out what coverage, you have for group therapy. Please visit Dawn's website to see a list of insurance companies she participates in. Call 443-590-0030 to schedule your individual assessment appointment and for more information regarding possible insurance reimbursement. You will be told what your co-payment, per class session, will be based on your insurance coverage by Dawn’s office. If you choose to utilize your insurance coverage through Dawn the co-payment for Nancy Lum will be $25.00 per 90-minute session. Nancy’s co-payment is to be paid at the beginning of each class, or can be paid in full for all sessions at the beginning of the first session. A nutrition receipt, coded for weight-loss, will be provided to you at the end of the series for the total cost incurred. You may then attempt to submit to insurance for reimbursement of her services; we cannot guarantee reimbursement. We do not accept Medicare Assignment.

Missed Meetings and Cancellations: ○

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Because this is a 7-part series there are no “make-up” days if a meeting is missed. We are creating a small group series and when people miss sessions it disturbs the cohesiveness of the group and all materials for the series are pre-purchased by facilitators this why a commitment to attend all series is required. See Patient Agreement for details. There is no reimbursement for missing meetings unless extenuating circumstances are approved by group facilitators. Cancellation: Should you decide to cancel your participation in this series please do so no later than 1 week prior to its start date. We can only have up to 15 participants in any one group, we will only be running one group at a time, per series, so there may be people waiting to get into the series you are cancelling. Please call 443-490-1240 to cancel your enrollment.

Returned Checks: ○



If a check is returned unpaid, there will be a $50.00 Insufficient Funds Fee (NSF) charge and personal checks will no longer be accepted as a method of payment.

financial policy STRIVE 8-10-2012HN

Late Payment Fees, as a result of returned checks and/or meetings that remain unpaid for: ○ ○

A late payment billing charge of $50.00 will be applied to any account which has a balance ≥ 30 days past due. Each additional month your balance is outstanding will be assessed $25.00. Late fees will not exceed 100% of your original balance or $150.00, whichever is greater. Accounts >60 days past due will be sent for legal action/ collections, you will be responsible for additional fees associated with this process. (ex. Court costs, legal fees, etc.) Initial

Services: ○


If you have enrolled in one of our series previously and dropped out, or neglected to complete all the meetings included, within 12 months from your initial date of service, you will be required to re-enroll in the program and pay the current fee for services.

I, the undersigned, assume financial responsibility as stated above and responsibility for all charges and fees if my account becomes past due. I have read, understand, and agree to this Financial Policy. I also understand future meetings may be denied if my account becomes past due until my balance to this office has been paid in full. Fees are subject to change without notice. X ________________________________________________________________________ Signature of Patient

___________________________ Date

financial policy STRIVE 8-10-2012HN

Strive Financial Policy