Billing Policy

 
 

FEES FOR SERVICE:

At the time of scheduling an appointment you accept that you will pay the fee associated for the service indicated on the website listed under the payment portal. When booking your appointment, you will be charged $150, half the fee of a full appointment, that goes toward your one hour appointment fee. Payment of the remaining balance will be charged to your on-file card upon completing the appointment. This totals $300 per one-hour appointment.

  • Requests to reschedule can be accommodated at no additional charge only if request is made greater than 48 hours in advance of the time of the original appointment.

  • A non-refundable deposit to hold the appointment will be made prior to your visit. This will total $150 and will cover the first half hour of your appointment.

  • Cancellations made less than 48 hours in advance will not be refunded the $150 deposit fee.

  • Incomplete or inaccurate information provided may result in the need for another consult and additional fees.

  • If I ‘No-Show / No-Call’ for my appointment, defined as not being present for your appointment more than 15 minutes after the scheduled time, you will be billed a no-show fee equal to a 30 minute session, $150, that will be required to be paid prior to rescheduling.

  • I understand that each initial genetic counseling session may last beyond the 30 minute time up to 60 minutes maximum.

    • If the initial time is exceeded, an additional appointment may need to be scheduled at the same follow-up rate billed in 30 minute increments.

  • I understand that if I am late to the appointment, I will still have to end the session at the allotted time.

  • It is policy to charge for other professional services you may require such as: telephone conversations which last longer than 15 minutes or attending meetings or consultations with other professionals which you have authorized.

PAYMENT CONSENT:

I authorize Clover Genetics to charge my credit/debit/health account card for professional services and auto-pay after the session is complete unless requested otherwise in writing by the patient or family.  I recognize that Clover Genetics has the right to charge my card as a late cancel or no show as described above if I do not show up for the appointment.  I will be billed for the full 30 minute session charge based upon the rates published on Clover Genetics at time of scheduling. I verify that my credit card/payment information provided is accurate to the best of my knowledge. If this information is incorrect or fraudulent or if my payment is declined, I understand that I am responsible for the entire amount owed and any interest or additional costs incurred if denied. I also understand by signing and initialing this form that if no payment has been made by me, my balance may be forwarded to collections as allowed by law if another alternative payment is not made within thirty days.

PROCEDURES REGARDING LEGAL PROCEEDINGS:

For any legal proceedings initiated or requested by the patient or their representatives, any attorneys requiring confidential information on clients will be billed for the information released, the time required to compile the information and any materials or postage necessary. The attorneys will also be billed for all court costs incurred. This will include preparation time, actual court appearance, and travel time. The fee involved for these services will be $100.00 per hour. In the event that the attorneys fail to pay for these services, the balance due will be the responsibility of the person or persons signing this Agreement. Be advised that insurance DOES NOT cover this and would be considered a full out of pocket expense, required to be paid in full upfront.

INSURANCE:

Out-of-Network: At this time, Clover Genetics does not accept most insurances. A copy of your receipt may be used to submit to your insurer for reimbursement, but this is your sole responsibility. Clover Genetics will not advise on the likelihood of coverage or process insurance submission at this time. I understand if I involve my insurance for payment that I am responsible for knowing my co-payment amount and deductible amount, but that I will have to pay the Out-of-Pocket fees up-front before appropriately requesting reimbursement from my insurance. I understand that these charges are an Out-of-Pocket expense and that my insurance carrier may not reimburse these charges.

Authorization to Pay Insurance Benefits: By signing below, if I choose to involve an insurance provider, I hereby authorize payment directly to Clover Genetics. I understand that I am financially responsible for all fees incurred and for fees not covered by this authorization. I authorize the release of my medical information to my third party payer in order to obtain payment for insurance reimbursement purposes if I choose to bill insurance. I hereby authorize Clover Genetic to release any medical information required for assessment. I understand that payment is expected prior to rendering of services unless other arrangements have been made. I have completed this form fully and completely, and certify that I am the patient or duly authorized general agent of the patient, authorized to furnish the information requested. I understand that even if I have some type of insurance coverage, I am responsible for full payment of services.