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289 Independence Blvd, Pembroke 3 , Ste 221, Virginia Beach, VA 23462
 
 
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Bruder Counseling Center
Patient Information
PLEASE PROVIDE RECEPTIONIST WITH INSURANCE CARD(S)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If employed:
 
 
 
 
 
 
 
 
INSURANCE INFORMATION
 
 
 
 
 
 
 
 
 
COMPLETE INSURED INFORMATION ONLY IF DIFFERENT THAN PATIENT INFORMATION
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bruder Counseling Center
Financial and Patient Privacy Policy
The counselor and staff of Bruder Counseling Center are here to serve your needs as a patient. It is a goal to create an experience for our patients that hopefully will limit the amount of stress patients may encounter. Our PATIENT FINANCIAL POLICY is intended to describe our expectations regarding the payment for services we provide. Unless otherwise noted, payment is due at the time of service.
Our staff is prepared to provide patients with any assistance possible in making payment arrangements for services. We can help patients contact the appropriate entities to obtain the documents needed to insure proper payment such as referrals and pre authorizations for services. We ask that patients recognize their responsibility to understand what services their insurance covers as well as what documents are required to assure the payment is made.
The FINANCIAL POLICY details the expectations of our counseling cetner as they relate to patients making payments for provided services. Patients should review the following policy requirements:
  1. The patient or their designated guarantor is responsible for payment of services.
  2. All office charges, co-payments, and applicable deductible amounts are due at the time of service, for your convenience the office manager can keep your credit card # on file.
  3. The provision of an insurance card for payment or services will be accepted and filed on behalf of the patient: however, the patient is responsible for their payment if their insurance company fails to adequately provide payment within 60 days.
  4. It is the obligation of the patient to obtain and provide any referral notifications required by the patient's insurance carrier. Without the proper referral the patient's appointment will be cancelled.
  5. Patient account balances are due within 30 days of receipt of the billing statement. If payment is not received collection proceedings will begin. Delinquent accounts will be assigned to a collection agency. All collection costs including court cost, collection agency fee of thirty three percent (33%), attorney fees, and interest will be added to the outstanding balance.
  6. After 90 days, if no arrangements have been made for payment, or if no payments have been received, then collection proceedings will begin.
  7. We accept MasterCard, Visa and Discover card. Checks returned for non-sufficient funds will be charged a $35.00 service fee.
  8. THERE IS A $50.00 MISSED APPOINTMENT FEE. A missed appointment is defined as a failure to come to a scheduled counseling session or failure to contact our office 24 hours before counseling session. After two failed appointments all future appointments will be cancelled until the patient calls their therapist.
PRIVACY ACT STATEMENT
It is the policy of Bruder Counseling Center not to share personally identifiable information with outside parties without prior approval from the owner of that information. Bruder Counseling Center abides by all local, state and federal regulations regarding the protection of private information (for example, the federal Health information Portability and Accountability Act of 1996). A detailed privacy statement may be requested from our staff.
We ask each patient/guarantor sign this document as part of his or her registration at Bruder Counseling Center in accordance with the following statement.
 
 
"I
 
 
, (patient/guarantor), acknowledge that I have read the above policies."