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Tranquility BHC Fees and Insurance Consent Form



Initial Psychiatric Evaluation: $250.00 (60-minute evaluation)

Monthly Medication Management Follow-Up Visit : $125.00 (5 to 20 minutes)

90-day Follow-Up Visit: $150.00 (15 minutes)

Pharmacy Change Fee: $15.00 ?

Urine Drug Screen Cup (Mandatory): $25.00 ?

TOVA Testing $175.00 (30 minutes)

No-Show Fees/Phone Consultation (after hours): $250.00 for any time over 5 minutes

Follow-up No Show Fee $100.00 New Patient No Show Fee $250.00

TMS (Transcranial Magnetic Stimulation Therapy) 36 treatments (required) Please contact the office for pricing as it varies based on the patient's insurance benefits

Notarization Fees ($5.00 - $25.00) (payments are to be made directly to Notary via the notary's provided payment link/method)


Financial Policy and Fees:

Payments of all copays, deductibles, balances, and/or coinsurance are due at the time of service no exceptions. If we have not received insurance payment within 30 days of your last visit, you will be responsible for the cost of the entire visit. If your insurance deems your claim not medically necessary, you will be responsible for the cost of the entire visit. We accept most insurances. Please be aware that verification of coverage by your insurance company is not a guarantee of payment for services. You will be personally responsible for all non-covered or denial of services rendered. It is your responsibility to know the benefits and coverage of your insurance policy. We will bill your insurance on your behalf. If we are not on a specific insurance panel and are considered out of network, you will be financially responsible for the cost of the entire visit. Payment is due at the time of service. We accept most major credit cards We do not accept checks We are more than happy to provide you with a Super Bill to submit to your insurance company for possible reimbursement. Please notify our billing department within 72 hours of your scheduled appointment, if you need to change your method of payment or if there are any changes to insurance since your last visit. If you have not notified us within that timeframe we will need to reschedule your appointment until our billing department has verified your insurance.

By signing this document, I indicate I have knowledge, understanding, and agreement with these standards nd company fees.

Good Faith Estimate

Good Faith Estimate According to Section 2799B-6 of the Public Health Service Act, healthcare facilities and providers are required to notify patients without health insurance coverage and you are not seeking to file a claim for services may request a ?Good Faith Estimate? of potential charges. It is your right to request and receive a ?Good Faith Estimate? explaining how much your visit will cost. Health care providers are required to provide you with an estimated cost for medical or mental health services. ? Disclaimer This Good Faith Estimate shows the costs of services that are reasonably expected for the expected services to address your mental health care needs. The estimate is based on the information known to [us/me] when [we/I] did the estimate. ? The Good Faith Estimate (GFE) does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill. ? If you are billed for $400 more (per provider) than this Good Faith Estimate (GFE), you have the right to dispute the bill You may contact our billing department at (832) 879-2107 to let them know the billed charges are at least $400 higher than the GFE. You can ask them to update the bill to match the GFE, ask to negotiate the bill or ask if there is financial assistance available. ? You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. ? There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this GFE. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. ? To learn more and get a form to start the process, go to: www.cms.gov/nosurprises or call CMS at 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059

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