Method of Payment and Insurance Pre-Authorization Registration Form

1) I authorize use of this form to convey my personal and insurance information to Insight Wellness Center
2) I authorize release of information to my insurance company for claims billing purposes.
3) I authorize insurance payments directly to the provider of service when they are considered a "Network Provider" or when my benefits allow it.
4) I understand I am responsible for the full amount of my bill for services provided. Cash, Check and Credit Card are accepted.
5) There is a 24-HOUR cancellation policy. I understand I will be billed IMMEDIATELY for the cash rate if I do not cancel at least 24 hours in advance of my appointment. Insurance does not cover no show/late cancellations; Missed session fee=$50 for Medicare plans and $100 for other insurance or Private Pay accounts.
6) In the event that my account goes unpaid for more than 90 days I acknowledge it may go to collections and I will be responsible for the balance due plus 30% collection fee.
7) Payment for services is ultimately my responsibility as insurance cannot be guaranteed.

1) I authorize use of this form to convey my billing information to House Medical Billing Service; Victoria House, Billing Manager/Owner.
2) I authorize release of information to my insurance company (if applicable) for claims billing purposes.
3) I authorize insurance payments (if applicable) directly to the provider of service when they are considered a "Network Provider" or when my benefits allow it.
4) I understand I am responsible for the full amount of my bill for services provided. Cash, Check and Credit Card are accepted.
5) There is a 24-HOUR cancellation policy. I understand I will be billed IMMEDIATELY for the cash rate if I do not cancel at least 24 hours in advance of my appointment. Insurance does not cover no show/late cancellations; you will be expected to cover the amount insurance would pay or the normal rate you would pay for attending your appointment.
6) In the event that my account goes unpaid for more than 90 days I acknowledge it may go to collections and I will be responsible for the balance due plus 30% collection fee.
7) Payment for services is ultimately my responsibility as insurance cannot be guaranteed.

1) I authorize use of this form to convey my billing information to House Medical Billing Service; Victoria House, Billing Manager/Owner.
2) I authorize release of information to my insurance company (if applicable) for claims billing purposes.
3) I authorize insurance payments (if applicable) directly to the provider of service when they are considered a "Network Provider" or when my benefits allow it.
4) I understand I am responsible for the full amount of my bill for services provided. Cash, Check and Credit Card are accepted.
5) There is a 24-HOUR cancellation policy. I understand I will be billed IMMEDIATELY for the cash rate if I do not cancel at least 24 hours in advance of my appointment. Insurance does not cover no show/late cancellations; you will be expected to cover the amount insurance would pay or the normal rate you would pay for attending your appointment.
6) In the event that my account goes unpaid for more than 90 days I acknowledge it may go to collections and I will be responsible for the balance due plus 30% collection fee.
7) Payment for services is ultimately my responsibility as insurance cannot be guaranteed.