ALL PAYMENTS ARE DUE AT THE TIME OF SERVICE: WHETHER YOU HAVE A COPAY, COINSURANCE, UNMET DEDUCTIBLE, CANCELLATION/NO SHOW FEE, OR SELFPAY.

If the patient is a minor, the parent/guarantor will be responsible for making or arranging for payment of Services

Our office does NOT accept any personal checks.

We require at least 48 business hours notice if you need to cancel or reschedule an appointment. If our office is closed, you MUST leave a voicemail or send us a message through our website or a text message. Failure to comply will result in a $65 fee for appointments with all providers. All fees are due at the time of your next appointment and can increase at any time at the discretion of the office. We will submit claims directly to insurance plans we contract with. If payment is not received from your insurance 60 days after the date of service, it will become the patient's responsibility. It is ultimately your responsibility to check with your insurance company to determine covered benefits.

PLEASE REMEMBER: The agreement of the insurance carrier to pay for health care is a contract between you and the insurance company, Any questions or complaints should be directed to your insurance company.

OTHER FEES: There may be associated fees that apply for medical records, completion of forms, and reports. I hereby authorize Positive Beginnings, to file all medical claims with any/all insurances in which Positive Beginnings participates. I hereby authorize payment of insurance benefits to be made to Positive Beginnings

I hereby authorize Positive Beginnings, to file all medical claims with any/all insurances in which Positive Beginnings participates. I hereby authorize payment of insurance benefits to be made to Positive Beginnings. I understand that all claims will be my responsibility 60 days after the date of service. I also understand that I will have a card on file and authorize Positive Beginnings to collect directly any balances owed including copays, outstanding deductibles, no show fees, etc. I further understand that if my insurance company denies any/all services as “noncovered”, “coverage terminated", "preexisting", or a "noncovered member", I will be responsible for payment within 30 days of said denials, or within 30 days of the first billing statement sent by Positive Beginnings following the receipt of said denial. I understand that I will be legally responsible for all collection costs associated with the collection of this account including court costs, reasonable attorney fees, and any other expenses incurred with collection if I default on any unpaid balance. I fully understand the above policies and agree to be financially responsible for any and all incurred charges for this account.

This summary describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

We understand that your medical information is personal to you, and we are committed to protecting this information. As our patient, we create medical records about your healthcare for you and the services and/or items we provide to you as our patient. By law, we are required to make sure that your protected health information (PHI) is kept private.

How will we use or disclose your information?

Here are some examples: (For more detail, please refer to the Notice of Privacy Practices that is available at the front desk)

• To obtain payment for our services
• In emergency situations For appointment and patient recall reminders Health Care Operations Monitoring Public Health Risk and Safety In response to certain requests arising out of lawsuits or other disputes

If you believe that your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, please contact our Office Manager, All complaints must be submitted in writing. You will not be penalized for filing a complaint.

You have certain rights regarding the information we maintain about you.

The right to access/copy The right to amend The right to an accounting of disclosures The right to request restrictions The right to a paper copy of this notice The right to request confidential communications

By signing my name below, I acknowledge that I was provided a copy of the Notice of Privacy Practices (NPP), and that I have read (or had the opportunity to read if so chose) and understand the Notice of Privacy Practices (NPP) and agree to its terms.

1. MEDICATION REFILLS: Medication refills are the responsibility of the patient and all requests should be submitted with a minimum of 3 working days notice. Urgent requests for medication refills might not be entertained. All controlled substance refills are to be done at the time of appointment with the provider. It is the responsibility of the patient to make sure that they do not run out of their medication.  If you need an urgent refill for controlled substances and are not able to get an appointment you will need to go to the ER. If you lose your controlled substances bottle of medication or prescription you will be responsible for reporting it to the police and getting a police report before an early refill is done by the provider.

2. Providers at Positive Beginnings do not participate in any legal matters including depositions, court cases, explored testimony, disability court appearances, etc. By signing this you are agreeing that your attorney will not be involving the providers in legal matters of any nature.