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Behavioral Health Financial Policy

Last Updated: October 10, 2023

Behavioral Health Financial Policy

This Behavioral Health Financial Policy describes PM Pediatric Care’s (hereinafter, “PM Pediatric Care,” “us,” “we,” or “our”) policies and procedures with respect to payment for behavioral health services.  It also describes the methods of payment available to each patient, or the patient’s parent or legal guardian (hereinafter, “you”), and other important information about our billing practices (such as charges for late cancellations and missed appointments).  You should review this policy carefully and call (888) 764 – 4161 if you have any questions.

Private-Pay Patients

If you do not have insurance coverage, your insurance does not cover the cost of these behavioral health services, or if we do not participate with your insurance plan, then you will be registered as a “private-pay” patient.  This means that, at the time of service, you will be paying by debit/credit card and we will not bill insurance for the services provided. You are responsible for all fees related to the services provided to you by PM Pediatric Care. You understand that the fees are due in full on the date of service.  You understand that for all services provided, neither you nor PM Pediatric Care may submit claims for these services for insurance billing, except that if you have commercial insurance coverage then you may submit for out-of-network reimbursement.

Patients with Participating Insurance

If we participate with your insurance plan, then we will submit a claim for the services provided for reimbursement by your insurance.  You understand that, even when claims are submitted to your insurance plan for reimbursement, you nevertheless accept personal responsibility for all co-payments, deductibles, and non-covered services, as dictated by your insurance plan, plus any collection costs for amounts personally owed by you.  Generally, once your insurance plan has processed your claim, they will send an Explanation of Benefits (“EOB”) to both you and our office, showing your total patient responsibility for the cost of the services.  Upon receipt of the EOB, our billing department will determine if there is a remaining balance owed by you based on your insurance plan’s adjustment/payment.  If there is an additional balance, you will be responsible for paying any such balance due to us.

Patient Billing and Credit Card on File

You agree to allow us to keep your credit card information on file in our HIPAA-compliant, secure credit card processor.  You hereby authorize us to charge your credit card for the cost of the services for which you are financially responsible.

You understand that all bills are to be paid immediately upon receipt.  You also understand that in the event your account is transferred to a collection agency due to your failure to pay for the services, that you will be responsible for any reasonable attorney’s fees and collection fees incurred by PM Pediatric Care in collecting payment, in addition to the amount of the bill.

Late Cancellation and No-Show Policy

Our goal is to provide excellent care to all patients in a timely and consistent manner. To be equitable to all our patients and mindful of our medical team’s time, our program enforces a no-show/late cancellation policy where allowable.  The following policy applies to all patients except for those with Medicaid coverage (either for primary or secondary coverage).

We require our patients to provide us with 24-hours’ advance notice of the need to cancel or reschedule an appointment.  A “late cancellation” is considered any appointment cancelled with less than 24-hours advance notice to PM Pediatric Care.  You agree to pay a late cancellation fee in the amount of $50.00 for any late cancellations.  You authorize us to charge the credit card on file to collect the late cancellation fee.

Similarly, we require our patients to provide notice in advance if they cannot make it to their scheduled appointment.  A “no-show” is a patient who fails to arrive for their appointment or any patient who arrives for their scheduled appointment more than 15 minutes late.  You agree to pay the full visit fee for any such missed appointment, and you hereby authorize us to charge the credit card on file to collect the no-show fee.

Moreover, you understand that PM Pediatric Care may dismiss you as a patient after three “no-shows.”  In such cases, we will honor a thirty (30) day grace period to allow you to get medications, make arrangements for alternate medical care, and request your medical records.  You may request to be seen again by the PM Pediatric Care behavioral health team after one calendar year, which will be granted at the discretion of our medical team.

You are personally responsible for the cost of any late cancellation or no-show fee, as these charges may not be submitted to your insurance plan for reimbursement.


By acknowledging your receipt of this policy, you affirm that you have read and fully understand this form and have been given the opportunity to ask questions, and that all your questions have been answered to your satisfaction.