TMS Health Solutions - Financial Agreement
Patient Information and Financial Policies
We require that you read and sign this document prior to receiving treatment.
This is an agreement between TMS Health Solutions, as creditor, and the Patient, Guardian/Guarantor, or Parent as debtor, named on this form. In this agreement, the words “you,” “your,” and “yours” mean the patient/debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words “we,” “us,” and “our” refer to TMS Health Solutions.
- Please bring your current driver's license or picture identification and health insurance card to every office visit.
- Please notify the office of any changes in insurance, address, telephone or family status.
- Payments such as co-pays and deductibles are collected at the time of service. We accept credit card, debit card, cash and checks.
Patients are responsible for full payment if:
- You do not have insurance,
- TMS Health Solutions does not participate with your health plan,
- You are unable to present a valid member identification card from your health plan at your visit, or
- We are unable to verify your insurance coverage.
- You should receive a bill for any other patient responsibility within 30 days; and an explanation of benefits (EOB) from your health plan. If you do not, please contact the billing office at 844-867-8444. Your current balance will be charged to your credit card on file.
Statements: For balances on your account, a statement will be sent. It will show previous balances, any new charges to the account, and any payments/credits applied to the account during the statement period.
Payments: Patient balances are due and payable when the statement is issued and is past due if unpaid after fifteen (15) days. If balance is not paid within 30 days, a $25 late fee may be assessed. If balance is not paid within 60 days, another $25 late fee may be assessed.
Payment Options if you have Insurance: Your health plan requires us to collect all co-pays and other patient responsible amounts at the time of service. We reserve the right to reschedule your appointment if you are unable to pay your co-pay or patient account balance. Missed appointment or late cancellation due to insurance issues may result in the $175 late cancellation fee if cancelled without 2 full business day notice. If you have not met your deductible, we will estimate the expected insurance payment for your visit and request that amount at the time of service, and you may receive a statement with additional balances after your visit.
Payment Options if you have No Insurance: Unless arrangements are made in advance, we will collect full payment at your visit by cash, check, credit/debit card, or CareCredit on the day of your visit.
Insurance: It is the responsibility of the cardholder to know what their eligibility and coverage is with their insurance carrier. We suggest that you verify coverage limitations prior to your visit. Although we will estimate your co-payment for your visit, it is the health plan that makes the final determination of your financial obligations and eligibility for services. You agree to pay any portion not covered by your health plan. If your health plan has not processed your claim within 60 days from the date of service, the balance will automatically be sent to you. Your signature indicates that you authorize TMS Health Solutions to bill your health plan directly for services rendered and for your health plan to make payment directly to TMS Health Solutions.
Past Due Accounts: If your account is past due, we will take the necessary steps to collect this balance by charging your credit card on file. If we must refer your account to a collection agency, reasonable attorneys' fees and reasonable collection expenses may become your obligation as permitted by law. If we need to send the account balance to collections because of non-payment, our provider may no longer be able to provide further care. The person responsible for the account will be notified of this by certified mail and given adequate time to find a new psychiatric provider. All accounts sent to the collection agency will be reported to the Credit Bureau. You give TMS Health Solutions permission to use all contact information including but not limited to cell phone, home phone, relative phone, home address, relative address and any other information gathered during the information gathering process. For us to service your account or to collect any amounts you may owe, we may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.
Returned Checks: There is a fee for any checks returned by the bank. This amount may change without notice.
Insurance Release: My health plan may not be liable for service rendered if any of the following conditions apply:
- I have not made premium payments to my health plan and I am in default of my contract;
- TMS Health Solutions does not participate in my health plan;
- I have not met the deductible under my health plan contract;
- Certain services may not be covered by some insurance plans.
Copies and Transfer of Records: We charge $25.00 for copies of your medical records.
Effective Dates: Once you have signed this agreement, you agree to all of the terms and conditions contained herein for this and any future visits, and the agreement will be in full force and effect.
I have read this Patient Information and Financial Policy as outlined and understand that I am ultimately responsible for the charges incurred by me or by my child/children as their legal parent or guardian. By executing this agreement, you are agreeing to pay for all services that are received.
PLEASE NOTE: A signed copy of this agreement will remain in your electronic health record. You may request a signed copy for your records.