Acknowledgement of Fees

All fees are due at the time of service and payable by cash, check or credit card (Visa, MasterCard or Discover). Checks should be made payable to “For You Behavioral Health.” There will be a $30 dollar fee for any returned / “bounced” checks or declined credit cards. Accounts that are delinquent may be sent to collections.

I further acknowledge:

  • For You Behavioral Health, LLC may not currently accept my insurance carrier and therefore they will not bill my insurance for reimbursement.
  • I understand that I am therefore responsible for the current fee-for-service or cash fee charged by the practice.
  • I understand that I may request a Superbill from the practice to be uploaded to my patient portal and it will be my responsibility to submit a paid bill to my own insurance company for reimbursement of my paid fee-for-service. I understand Reimbursement is not guaranteed.
  • I also understand that the practice may in the future begin billing my insurance carrier or other third-party payor.
  • I understand that at times, insurance companies do not fully reimburse services, regardless of whether the provider is in- or out of-network. Situations such as this may occur when the insurance company does not consider the service rendered “medically necessary,” or an experimental or investigational service, diagnosis or certain fees. Services considered not medically necessary vary depending on my insurance company. This may also occur when insurance companies reimburse fewer hours than billed.
  • I understand that it is my responsibility to verify coverage prior to consenting to services. While the practice will make every effort to verify benefits and coverage prior to beginning services, I am ultimately responsible for knowing coverage limits and am responsible and liable for all remaining charges.
  • I understand For You Behavioral Health, LLC reserves the right at any time to modify its client fee agreement. You will be notified of changes in fees and required to update your fee agreement before further services are provided to you.

Credit Cards

At For You Behavioral Health, LLC we require patients to keep a credit card on file as a convenient method for all payments for
which you are liable for. Your credit card information is kept in a PCI-compliant system. You can go to the patient portal and
add/update credit card information yourself or we are happy to do it for you. A credit card is used to reserve your time for an initial consultation. If you are unable or unwilling to place a credit card on file and update it as needed, you will be required to pay your balance prior to your visit.

We will charge your credit card on file for the following:
1. On the day of appointment or any otherwise outstanding balance owed after two billing cycles (60 days).
2. Late cancellation and/or no-show fees - these will be charged on the day of the missed appointment.
3. Other miscellaneous fees as described in the office policies.

Any outstanding fees/overdue accounts of ninety (90) days or more (from the date of service provided) may be reported to a credit bureau, collection agency and/or attorney. By signing this agreement, you consent to the re-release of your contact information to such institution(s) as needed to seek reimbursement for your overdue account. In addition, you agree to pay all reasonable costs, including, but not limited to, interest and reasonable attorney fees.
I, the undersigned, authorize and request For You Behavioral Health to charge my credit card for balances due at time of service.

This authorization relates to all services provided to me by For You Behavioral Health, LLC. This authorization will remain in effect until I cancel this authorization. To cancel, I must give a 60-day notification to For You Behavioral Health, LLC in writing and the account must be in good standing.

Copyright © 2024 For You Behavioral Health, LLC
All Rights Reserved.

Florida Telehealth

17A Green Street
Concord, NH 03301
Office: 1-603-522-7039
Fax: 1-888-251-0541