| What is your financial policy? All payments must be made at or before the time of service delivery. We provide appropriate documentation which allows our patients who choose to file for reimbursement the documentation they need to do so. We do not deal directly with health insurance companies, nor do we complete or sign forms, provide treatment plans, or forward records. We accept checks, cash and credit cards Our services are provided by appointment only and when a patient schedules an appointment, time is reserved for that patient and not available to others. Missed appointments, as well as those cancelled with less than a minimum 24 business hours’ notice (48 hour minimum on extended sessions and 1 full week minimum notice on intensives, which are appointments over 120 minutes scheduled in one day) will be charged the fee for the visit. A current, completed Missed Appointment/Payment of Services Credit Card Authorization will be held on file for each patient to cover missed appointment, prescription refills, phones contacts and sessions and other billable services. For those patients who are receiving assistance from family members or other third parties, we have an authorization to charge a credit card form that may be signed by the card holder. A copy of the card, front and back must accompany the form and the agreement also applies to payment of missed or late cancelled sessions as well. Payment is still due at or before the time of service. No credit card will be accepted if the presenter is not the card holder unless we have the signed credit card form on file. We also offer the option of Pay Pal on our website. You do not need a Pay Pal account in order to use this service. When utilizing Pay Pal allow extra time for funds to be received (usually 2 business days) before a service is requested or an appointment scheduled. Financing for treatment is also available through third party behavioral health care financing companies. It provides an opportunity for individuals to obtain the treatment they need now, at a frequency which is more beneficial to their overall treatment, while making monthly payments that are lower than the services received. We do not offer financing through our office, but felt that it would be worthwhile to mention this option so that interested parties could look into it. |

| Stonebriar Psychiatric Services, P.A. 972-335-2430 |
