“Our relationship with money and time reflects how we value ourselves and others”
Thank you for choosing us as your wellness provider. While your wellness is our priority, we still must cover this often uncomfortable topic about payments & missed appointments.
At BN Counseling we respectfully request for your credit card information to ‘hold’ your reserved appointment, similar to when reservation agents ask for a credit card to hold a hotel room or a table at a restaurant. This helps reduce no-shows, ensures the appointment is paid for late cancellations & missed appointments.
Insurers won’t cover cancellation fees, and most plans prohibit practitioners from charging their members. Call the member number at the back of your insurance card if you would like to verify. We have a “Questions to Ask Your Insurance” form to guide you.
Patients have the option of mailing in a check instead, which we cash only if they don’t show up or fail to cancel the appointment in time. Our office charges a $30 fee for any check returned for any reason.
We understand that on rare occasions, issues may arise causing you to miss your appointment without the ability to notify our office prior to your appointment. Should you experience any unforeseen circumstance that causes you to miss your appointment, please call our office to have it rescheduled. Our policy is to charge for missed appointments not canceled 48-hours in advance.
MISSED APPOINTMENTS. Weekly standing appointments are what we call “your time” meaning that we will honor “your time” in expectation of rendering you professional & courteous service on a weekly basis. Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48 hours notice is required for re-scheduling or canceling an appointment. If you are unable to attend “your time,” please be aware that you will be charged for a full session. We understand that on rare occasions, issues may arise causing you to miss your appointment without the ability to notify our office prior to your appointment. Should you experience any unforeseen circumstance that causes you to miss your appointment, please call our office to have it rescheduled. Unless we reach a different agreement, a fee will be charged for sessions missed. Most insurance companies don’t reimburse for missed sessions. Also from a humanistic understanding, imagine what it’d be like to go to work & not get paid. Our clinicians have similar sustaining responsibilities as well. Please help us to serve you better by keeping your regularly scheduled appointment.
Here’s How Recurring Payments Work:
You authorize regularly scheduled charges to your checking/savings account or credit card. You will be charged the amount indicated below each billing period. A receipt for each payment will be emailed to you and the charge will appear on your bank statement as an “ACH Debit.” You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.
Please complete the information below:
I ____________________________ (full name) authorize BN Counseling, LLC to charge my credit card
indicated below for scheduled appointments for payment of my sessions/co-payment/co-insurance/deductible. These charges include full payments for missed appointment unless otherwise negotiated.
City, State, Zip:
|Checking/ Savings Account ☐Checking ☐Savings
Name on Acct ____________________
Bank Name ____________________
Account Number ____________________
Bank Routing # ____________________
Bank City/State ____________________
|Credit Card ☐Visa ☐Master ☐Amex ☐Discover ☐Other:
Cardholder Name _________________________
Account Number _________________________
Exp. Date ____________
CVV (3 digit number on back of card) ______