Payment & Billing
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This page contains authorization forms for credit/debit cards and insurance policies. PsychPhilly stores this data in a system that complies with HIPAA regulations.

Credit Card Authorization Form
By completing this form, I hereby authorize the billing department of PsychPhilly to charge the credit card listed below for my appointments. My card will be charged within 1 business day of a scheduled appointment unless a specific payment plan is chosen. Payment plans will utilize the card listed below on dates agreed upon by myself and the billing manager.
If I need to cancel or reschedule an appointment, I will provide 24 hours’ notice to the office. If I miss my appointment or cancel/reschedule with less than 24 hours’ notice, PsychPhilly will charge my card the missed appointment fee of $75.00. (barring emergency circumstances)
A valid debit/credit card is required on file for the entirety of my care at PsychPhilly.
Please complete the form below
Authorization to Bill Insurance
I understand that PsychPhilly will submit insurance claims on my behalf and that I’m responsible for any deductibles, co-pays, co-insurance, or uncovered costs. Full payment is due within one business day of my appointment unless other arrangements are made.
I am responsible for understanding my insurance benefits and confirming that PsychPhilly and its providers are in-network.
I authorize the release of relevant treatment information to insurance companies and healthcare providers as needed. I also authorize direct payment of insurance benefits to PsychPhilly. I understand my insurer may not cover the full cost of services, and I agree to pay any remaining balance.
Please provide information about your current insurance coverage
Billing Questions?
Send an email to our billing manager at drjones@hpcbilling.com with your billing & payment-related questions.