Life Balance, PLLC Please take a moment to fill out the form.
Welcome to Life Balance, PLLC. This document contains important information about our services and business policies. We can discuss any questions you have when you sign them or at any time in the future. Consent for Mental Health Services. I voluntarily consent for care encompassing diagnostic procedures and treatment by my physician/nurse practitioner, therapist, his/her assistant, designees or consultants, as may be necessary in the judgement of my physician/nurse practitioner. I also understand that I will be billed direct for those services provided. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made as to the results of treatments or examinations in this clinic. I understand that my medical record may be maintained on a computer-based system and is available to persons involved in my care.
Authorization to Release. I hereby authorize Life Balance, LLC and any provider caring for me to release or disclose to insurance companies and / or outpatient benefit programs and their designees all information from my medical record pertaining to my medical treatment as needed to process insurance claims.
Communication: I hereby authorize Life Balance, LLC to communicate with me via voice mail in the event I cannot be reached directly.
Release from Responsibility. If I should leave the clinic against medical advice or prior to treatment being completed, I hereby relieve said physicians/ nurse practitioner, therapists and the clinic of all liability for my action.
Guarantee. Life Balance, LLC is a fee-for-service mental health practice that strives to provide immediate care for patients needing its' services. I understand that I must pay for these services on the date care is rendered. I understand that Life Balance, LLC will file my insurance under out-of-network coverage benefits I may have.
Cancellation / No Show Policy: If you will arrive 15 minutes past your scheduled time, please call. It may be possible to work you in when an opening arises, accommodate you at the end of the day, or reschedule your appointment. I also understand that if I cancel a scheduled appointment less than 24 hours prior, or if I fail to show for a scheduled appointment, I will be responsible for payment equal to the normal fee for the scheduled service. Patients who no-show or cancel two (2) or more times without 24-hour notice may be required to secure next appointment with a credit/debit card or be dismissed from the practice and thus they will be denied any future appointment(s). Our fee to be charged to you for cancellation/No show is $50.00 and you will be required to pay this fee before another appointment will be made.
Payment Terms. I understand that payment in full is due on the date of treatment for all services provided, and I agree to pay all charges for the patient named below. If payment in full is delayed for any reason (such as the failure of my insurance to pay the balance in full), I agree to pay the full balance
I have read and initialed all of the above and I certify that I understand and agree to its content.
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