Payment & Billing

Customized for your needs

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 payment/credit card is required on file for the entirety of my care at PsychPhilly.

Please complete the form below

I have read and understand the terms outlined above.

I confirm

Patient Name

First Name

Last Name

Email

Phone

(###)

###

####

Name of Cardholder

Card Number

Expiration Date

numbers only

CVV Code

Three numbers on the back of card, or for Amex 4 digit code on front of card

Billing Zip Code

Digital Signature

By typing my name below, I hereby grant the use of this card for payment purposes.

Authorization to Bill Insurance

I understand that PsychPhilly will file insurance claims for me and that I am obligated to pay any deductibles, co-payments, co-insurance, or other costs that my insurance does not cover at the time services are rendered. Payment in full is due within 1 business day of a scheduled appointment unless other arrangements have been made.

I am aware of my obligation to comprehend the benefits of my insurance coverage. I am aware of my need to confirm that PsychPhilly and its providers are covered by my insurance plan.

I authorize the release of any information including the diagnosis and the records of any treatment or examination rendered to me or my dependents during the period of such care to third party payers and/or other health practitioners. I authorize and request my insurance company to pay directly to PsychPhilly insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Please provide information about your current insurance coverage

Name

First Name

Last Name

Insurance Company (e.g., Aetna, Cigna)

Policy or Member ID Number

Relationship to Insured Person

Are you the policyholder?

If "no," list First and Last Names of policyholder

Member Services Phone Number

Pharmacy Benefits Name (e.g., OptumRx)

Rx BIN:

Rx PCN:

Rx Grp:

Digital Signature

By typing my name below, I affirm that I understand the above information.

Billing Questions?

Send an email to our billing manager at drjones@hpcbilling.com with your billing & payment-related questions.

Payment & Billing

Credit Card Authorization Form

Authorization to Bill Insurance

Billing Questions?

Looking for appointment fees? Visit Fees & Insurance.