Financial PolicyThe following statement explains our financial policy which we ask you to read and sign. Please be advised that we are “in-network” with federal Medicare only, but will bill your primary insurance company as a courtesy and accept “out-of-network” benefits providing you have them. In some cases, we accept assignment of benefits but in all cases, we require that the guarantor, the person who is financially responsible, is personally liable for any balance not covered by insurance. It is your responsibility to understand and comply with any pre-determination of benefits or referral requirements. We do not bill secondary insurances but will take the information to assist you in completing the claim. Your first visit (a one-hour evaluation) at the rate of $350.00 must be paid at the time of your visit. We accept cash, checks and credit cards. For checks returned to us as unpaid by your bank, we will charge a $35.00 fee. Credit Card Payments can be made on the patient portal. Should your insurance Company pay you directly, you are required to endorse and submit the check to our office within five days. If you do not have “out-of-network” benefits, follow up visits are 30 minutes at a cost of $175.00. We have created an essential questionnaire to help you communicate with your insurance company regarding any benefits you may or may not have. The “Getting the Most from Your Insurance Company” form is available on our website to assist you in navigating your benefits: www.abcnnj.com. Due to the changing rules and regulations of the insurance industry it is YOUR responsibility to be knowledgeable of your own insurance plan prior to your visit. We recommend you call them first. Please understand that payment of your bill is considered a part of your treatment. Past Due Accounts Overdue accounts will be referred to a collection agency. Legal fees and collection fees that we pay to secure past due balances will be added to your account. Cancellations and Failure to Show We understand that sometimes appointments must be cancelled or re-scheduled. We ask that you provide at least a 24-hour notice. Patients that cancel less than 24 hours will be charged a $50 and any no shows billed at $75. Please understand that we value your time, we ask that you value ours as well. I have read and fully understand the ABC, NNJ financial policy as outlined above. By signing this form, I understand that I am financially liable for all services provided. Name* Date* MM slash DD slash YYYY Signature*PhoneThis field is for validation purposes and should be left unchanged.