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Treating the Toughest Cases of Depression and Brain Illness

Financial Policy

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The Neuroscience Center and its associated clinics believe that part of our comprehensive health care practice is to establish and communicate a financial policy to patients. We are dedicated to providing individualized treatment plans and exceptional care for you. In order to do so, it is important for you to understand our financial policy. If you have any questions, please contact our office.

PAYMENT: Unless otherwise specified, payment is expected at the time of your visit. We accept cash, check, or credit card. We do ask for a copy of an official ID card or driver’s license to confirm accurate patient identity.

INSURANCE: We are not a participating provider with insurance plans. Please remember that insurance is a contract between the patient and the insurance company and ultimately the patient is responsible for all payment
in full. We will work with insurance companies for GAP exceptions and single case agreements if necessary.

GAP EXCEPTIONS or PPO WAIVERS: In the event your insurance plan determines services to be covered under a gap exception and claim is paid, you will still be responsible for any remaining balance.
NON-COVERED SERVICES: Patients who insist on “day of” urgent/emergent scheduling or care after hours or on
days the clinic is closed will be assessed an additional urgent care or after-hours fee. These fees will be billed as
office charges.

LATE CHARGES: A charge of 12% annually will be applied to all patient balances 90 days old or greater.

RETURNED CHECKS: These will incur a $50.00 service charge. You will be asked to bring cash, certified funds or a money order to cover the amount of the check plus the $50 service charge to pay the balance prior to receiving services from our staff or the physician. Stop payments constitute a breach of payment and are subject to the $50 service fees associated with collections. All bad checks written to this office are subject to collections and will be prosecuted in Lake County.

ACCOUNTING PRINCIPALS: Payment and credits are applied to the oldest charges first.

FORMS FEES: We require a pre-payment for completing forms, copying medical records, notarizing, or for a written communication letter by the doctor. The charge is determined by the complexity of the form, letter, or communication. Base form charges are $10.00 per occurrence plus any applicable postage or notary fees. We must respond to a written request within 30 days of the receipt of the written request. If the office needs more time to comply, we will provide the requesting party a written statement of the reasons for the delay and the date by which the requested information will be provided.

• Page 1-25 costs $1.05 per page
• Page 26-50 costs $0.70 per page
• Page 50+ costs $0.35 per page

There is an additional handling fee of up to $27.91 and employee fee if applicable. If the medical record request is estimated to have more than 500 pages, we will charge $0.15 per page, additional handling fee and an employee fee.

BILLING OFFICE: If you have questions in regard to any of your billing statements, our billing department at 847-236-9310 will be available to assist you.

CANCELLATIONS OR MISSED APPOINTMENTS: If you do not cancel your appointment 48 hours before, or if you no-show, I will be responsible for paying the fee of your cancelled/no-show appointment.

RESPONSIBILITY FOR PAYMENT: I understand that I, personally, am financially responsible to The Neuroscience Center and its associated clinics for charges incured.

INSURANCES WE WON’T BILL: I am not currently eligible for Medicare, Medicaid, Tricare, or CHAMPUS. I will notify The Neuroscience Center/Hyperbaric Centers of Chicago/SrdBest/Pathfinder in writing immediately if I become eligible for these payors, thus terminating my care from The Neuroscience Center/Hyperbaric Centers of Chicago/SrdBest/Pathfinder. We do not accept these insurances nor bill these payors if patients switch after becoming established with The Neuroscience Center/Hyperbaric Centers of Chicago/SrdBest/Pathfinder.

RELEASE OF INFORMATION: I hereby authorize, MIND/ The Neuroscience Center/ Hyperbaric Centers of Chicago/ Srdbest/ Pathfinder to release information to governmental agencies, insurance carriers, or other financial agencies who are liable for professional and medical care. This may include all information that is needed to substantiate claims and payments.

COLLECTION FEES: In addition to the principle amount owed, I also agree to pay 30% of the unpaid balance if my account is turned over to a collection agency or attorney, in effort to collect any outstanding balance. This may include, but is not limited to, filing fees, court costs, collection agency fees and attorney fees.

DIVORCED PARENTS of PATIENTS: By signing below, the adult who signs a minor child into our practice on the day of service accepts responsibility for payment. This office does not promise to send bills or records to the other parent/guardian for issues of payment or communication. We will communicate about treatment and payment with the parent who signs in that day. Parents are responsible between themselves to communicate with each other about the treatment and payment issues.

MEDICARE/MEDICAID /3rd PARTY PAYORS WAIVER: You must be aware that The Neuroscience Center, LLC and/or Dr. Best AND Pathfinder Brain SPECT, LLC and have “opted out” of Medicare, Medicaid, and all 3rd party payors for all covered items and services furnished to said beneficiaries. I understand that I am responsible for full payment, at the time services are rendered. I understand that I am not allowed to bill Medicare, Medicaid, other 3rd party payors, or require Dr. Best (The Neuroscience Center, LLC) or (Pathfinder Brain SPECT, LLC) to bill Medicare, Medicaid , or other 3rd party payors for items or services furnished by The Neuroscience Center/ Hyperbaric Centers of Chicago/ Srdbest/ Pathfinder.

I understand that Medicare and Medicaid rates do not apply to The Neuroscience Center/ Hyperbaric Centers of Chicago / Srdbest / Pathfinder. I will not in any way, now or at any future time, attempt to collect a refund or reimbursement according to Medicare and Medicaid discounted rates, which are not provided through The Neuroscience Center/ Hyperbaric Centers of Chicago/ Srdbest/ Pathfinder. I have read and understand the practice’s financial policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice at any time.

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847-236-9310