I understand that I will be charged a fee for services received in accordance with the policies of WESTWOOD BEHAVIORAL HEALTH CENTER, INC. (WBHC) and the schedule below. Fees are based upon income verification and ability to pay. I also understand that fees for all services are due at the time of service.
I also understand that I may qualify for a discounted fee based upon family size and gross household income level. My fee share or co-pay per visit is:
I understand that certain insurance policies may pay a portion of the fees assessed for services received.
I agree to provide copies of membership card(s) and claim forms when required. I understand that I am responsible for the amount not covered by my insurance up to the full fee for service. I also understand that I am still responsible for my Co-Pay amount to be paid at the time services are received. If the sum received through insurance and client fee payments exceeds the fee for service, the excess paid will be reimbursed to the Client after all services, and claims for services, are processed.
I certify that I am eligible for payment through the following resources. Identification cards, etc. are to be provided upon request.
The signature below authorizes payment of MEDICARE benefits be made to Westwood Behavioral Health Center, Inc. for any services furnished by that physician or organization. I authorize the Health Care Financing Administration to release any medical information necessary to determine benefits payable for related services.
Income Source and Amount
*Loss of Medicare, Medicaid or Title XX status, will result in my being subject to the sliding fee payment schedule. Currently, the minimum sliding fee is $20.00 per visit/hour of service payable at the time of service.(to be completed by Westwood Behavioral staff)
I authorize payment of benefits directly to WESTWOOD BEHAVIORAL HEALTH CENTER, INC. for services rendered. I also authorize release of information (for insurance payment purposes only) that is protected by Federal Confidentiality rules (42 CFR, Part 2, Section 2.31 of PL-03-282). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR, Part 2. A general authorization for release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse patient. This information is also protected by HB 244 of the Ohio Revised Code (5122.3).
I also certify that I have read (or had read to me), understand, and have received a copy of Westwood Behavioral Health Center, Inc. fee policy, payment agreement, consent to treatment and confidentiality statement, Notice of Enrollment Disclosure, Notice of Privacy Practices and a copy of the Client Rights and Grievance Procedures. I understand that the Center does not discriminate against any individual based upon race, color, creed, sex, sexual orientation, national origin, religion, disability or economic situation including the ability to pay for services. The Center does not tolerate any form of harassment of clients or staff by any individual at any time. The Center is an equal opportunity employer and equal provider of services.
