WELLNESS CLASSES
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1855 N. Webb Road
Wichita KS 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.
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.
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.
