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PATIENT FORMS

Welcome to Affiliated Family Counselors.

We are here to help you in any way possible so please feel free to call the office with any questions you may have when completing your new patient paper work. If you are an adult there is no need to complete the “parent” section of the paper work. Make sure each page is signed, which will help when you arrive at our office. Please bring your photo ID, completed paper work and insurance card(s) and we will be happy to file all insurance claims for you. We will gladly check your insurance benefits for you prior to your appointment. If you are responsible for charges other than your copay / coinsurance you will be notified ahead of time so there are no surprises at your visit. All copays, co insurance and deductibles are due at time of service. If you are unable to attend your scheduled appointment, please kindly give us a 24 hour notice.

New Patient Form

Financial Policy Form

Mental Health Screening Form

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(316) 636-2888

Hours 8am – 8pm
24 Hour Answering Service

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Affiliated Family Counselors Offices

Main Office

1855 N. Webb Road
Wichita KS 67206

Polo Club Office Park

1223 N Rock Road
Building G, Suite 100
Wichita Kansas 67206

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Terms and Conditions:
The therapists and staff at Affiliated Family Counselors are committed to providing the best possible care. It is important to our professional relationship that you understand our fee and payment policies. Please review the following information carefully and sign as indicated. If you have any questions about our fees, our policies or your responsibilities, please let us know. All patients must complete the Patient Information Form prior to seeing our counselors. You are responsible for notifying our office of any patient information changes (i.e. address, name change, insurance change, etc.) Any charges incurred due to the failure to report changes of information are the full responsibility of the patient or responsible party. There is an Appointment Hold Fee of $50.00 to $100.00 depending on the type of appointment scheduled. This fee is used to hold the appointment and will be put toward the co-pay or deductible if you show up for the appointment. If you fail to show up for the first appointment or do not call 24 hours in advance to cancel, the Appointment Hold Fee will be kept by the agency. FMLA/Social Security paperwork is $35.00. Records is $25.00 plus 0.56 per page for retrieval and copies. Affiliated Family Counselors will file patient insurance claims upon receipt of complete insurance information including a photocopy of the insured’s card. We will bill secondary insurance, but if they do not pay then you will be responsible. We can bill a third insurance party if the correct information is provided. AFC will not become involved in disputes between patients and their insurance providers, however we will supply factual information as necessary. You are responsible for the timely payment of your account. This includes, but is not limited to: deductibles, co-payments, non-covered charges, and “usual and customary” charges. You will be notified by your insurance company of all payments made to AFC on your behalf and any non-covered charges or remaining balance on your claim. Please call our billing office to make payment arrangements upon receipt of a patient account statement indicating an unpaid account balance. AFC will do our best to assist in obtaining reimbursement for flexible spending accounts, however AFC will not become involved in account disputes. At your request, you will receive a receipt for services. In addition, AFC will provide you with a copy of applied account payments, once monthly, per patient request. Any additional reporting will be subject to administrative fees. If a referral is required for your insurance, it is your responsibility to obtain the referral prior to any appointments. Failure to obtain a referral may result in reduction of benefits and any non-covered charges will become the responsibility of the patient. Copayments and/or coinsurance are due in full PRIOR to being seen by a therapist.

I understand if I have an unpaid balance to Affiliated Family Counselors (AFC) and do not make satisfactory payment arrangements, my account may be placed with an external collection agency. I will be responsible for reimbursement of any fees from the collection agency, including all costs and expenses incurred collecting my account, and possibly including reasonable attorney’s fees if so incurred during collection efforts.

In order for, Affiliated Family Counselors or their designated external collection agency to service my account, and where not prohibited by applicable law, I agree that AFC and the designated external collection agency are authorized to (i) contact me by telephone at the telephone number(s) I am providing, including wireless telephone numbers, which could result in charges to me, (ii) contact me by sending text messages (message and data rates may apply) or emails, using any email address I provide and (iii) methods of contact may include using pre-recorded/artificial voice message and/or use of an automatic dialing device, as applicable.

Payment in full is due at the time of service unless prior arrangements have been made through the business office. We accept cash, checks, Visa & MasterCard. Any overdue balances may be considered for further collection action.

The charge for a returned check is $35.00, payable by cash or money order. This will be applied to your account in addition to the insufficient fund amount. You may be placed on a “Cash Only” basis following any returned check.

If the patient is a minor, the parent/guardian is responsible for full payment and will receive all billing statements.

Clients under the age of 18, who are not emancipated, and their parents, should be aware that the law may allow parents to examine their child’s treatment records. Because privacy is often crucial to successful progress, particularly with teenagers, we may request that the parents give up access to their child’s records. If they agree, we will provide the parents with a summary of the child’s treatment when it is completed unless the child is in danger or is a danger to someone else. In this case, we will notify the parents of the situation immediately.

A signed release to treat may be required for unaccompanied minors.

If you become involved in legal proceedings that require a therapist’s participation, you will be expected to pay for all professional time, including preparation and transportation costs, even if the therapist is called to testify by another party. Due to the difficulty of legal involvement, AFC therapists have a separate rate for preparation for and attendance at any legal proceeding.

In the event you would like AFC to share your patient record with another provider or physician, a Release of Records Consent must be completed. No patient information will be shared without a signed release on file.

You must read and accept our Service Payment Policy. By clicking on the “Accept” button you will continue to our secure payment portal.

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SELF-PAY & PRIVATE HEALTH INSURANCE PATIENTS
MEDICAID PATIENTS

SELF-PAY & PRIVATE HEALTH INSURANCE

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Terms and Conditions:
Appointment Cancellation Policy: There may be an Appointment Hold Fee of $50.00 to $100.00 depending on the type of appointment scheduled. This fee is used to hold the appointment and will be put toward the co-pay or deductible if you show up for the appointment. If you fail to show up –no-show– for the first appointment or do not call 24 hours in advance to cancel, the Appointment Hold Fee will be kept by the agency. A “no-show” is someone who misses an appointment without canceling it within a 24 hour working day in advance. No-shows inconvenience those individuals who need access to medical care in a timely manner. If it is necessary to cancel your scheduled appointment, we require that you call one working day in advance. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to timely care. To cancel an appointment, please call our office at (316) 636-2888. Again, if an appointment is not cancelled at least 24 hours in advance, you will be charged the Appointment Hold Fee; this will not be covered by your insurance company (see Appointment Cancellation Policy Terms & Conditions). Appointment Cancellation Policy Terms & Conditions: These Terms and Conditions, as may be amended from time to time, apply to all our services directly or indirectly made available online, through any mobile device, by email, or by telephone. By accessing, browsing, and using our (mobile) website or any of our applications through whatever platform (hereafter collectively referred to as the “Platform”) and/or by completing an appointment reservation, you acknowledge and agree to have read, understood, and agreed to the Terms and Conditions set out below. These pages, the content, and infrastructure of these pages and the online appointment reservation service (including the facilitation of payment service) provided by us on these pages and through the website are owned, operated, and provided by Affiliated Family Counselors and are provided for your personal, non-commercial (B2C) use only, subject to the Terms and Conditions set out below. By making an appointment reservation with Affiliated Family Counselors, you accept and agree to the relevant cancellation and no-show policy as outlined herein. All appointments require an Appointment Hold Fee or Deposit (hereafter called “Deposit.”). All appointments have a 24-hour cancellation period. In order to receive a refund of your Deposit, all appointments must be cancelled 24 hours prior to your appointment. No-show or cancellations without 24-hour notice will be charged the Deposit. No exceptions.

By clicking on the “Accept” button YOU ACKNOWLEDGE AND AGREE TO HAVE READ AND ACCEPTED OUR CANCELLATION POLICY AND UNDERSTAND YOU MAY BE CHARGED FOR ANY MISSED APPOINTMENTS OR CANCELLATIONS WITHOUT 24-HOUR NOTICE.

You will be redirected to our secure patient information portal.

ACCEPT
CANCEL

MEDICAID PATIENTS

Schedule an Appointment

Terms and Conditions:
Appointment Cancellation Policy: A “no-show” is someone who misses an appointment without canceling it within a 24 hour working day in advance. No-shows inconvenience those individuals who need access to medical care in a timely manner. If it is necessary to cancel your scheduled appointment, we require that you call one working day in advance. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to timely care. To cancel an appointment, please call our office at (316) 636-2888. Appointment Cancellation Policy Terms & Conditions: These Terms and Conditions, as may be amended from time to time, apply to all our services directly or indirectly made available online, through any mobile device, by email, or by telephone. By accessing, browsing, and using our (mobile) website or any of our applications through whatever platform (hereafter collectively referred to as the “Platform”) and/or by completing an appointment reservation, you acknowledge and agree to have read, understood, and agreed to the Terms and Conditions set out below. These pages, the content, and infrastructure of these pages and the online appointment reservation service (including the facilitation of payment service) provided by us on these pages and through the website are owned, operated, and provided by Affiliated Family Counselors and are provided for your personal, non-commercial (B2C) use only, subject to the Terms and Conditions set out below. By making an appointment reservation with Affiliated Family Counselors, you accept and agree to the relevant cancellation and no-show policy as outlined herein. All appointments have a 24-hour cancellation period. By clicking on the “I Accept” button YOU ACKNOWLEDGE AND AGREE TO HAVE READ AND ACCEPTED OUR CANCELLATION POLICY.

By clicking on the “Accept” button YOU ACKNOWLEDGE AND AGREE TO HAVE READ AND ACCEPTED OUR CANCELLATION POLICY AND UNDERSTAND YOU MAY BE CHARGED FOR ANY MISSED APPOINTMENTS OR CANCELLATIONS WITHOUT 24-HOUR NOTICE.

You will be redirected to our secure patient information portal.

ACCEPT
CANCEL