Gloria M Kardong MD DFAPA

FINANCIAL POLICIES

I understand that Dr. Kardong is not an in-network provider for any private insurance companies, Medicare nor Medicaid.  She does not take Worker’s Compensation cases.

You will receive a 1500 insurance form monthly which will serve as your receipt if you are self pay or may be submitted to your insurance company for reimbursement.

Telepsychiatry is a new field and billing/reimbursement practices are not well defined.  It is your responsibility to determine whether or not your insurance company will reimburse you for your telepsychiatry visits.

–Payment in full is required at the time of the visit irrespective of your insurance status.

–You must place a credit card on file before your initial visit.

This may be charged per the policies below.

Cancellation and Late Policy

New visits

1. “No shows” will be charged 100% of the assigned fee;
2. Cancellations within 48 hours of your appointment time: 50% of the assigned fee will be charged;
3. Cancellations outside of 48 business hours of appointment time: We will gladly reschedule and no fee will be charged.

Follow-up visits

1. “No shows” will be charged 100% of the assigned fee;
2. Cancellations within 48 hours of appointment time: 100% of the assigned fee will be charged;
3. Cancellations outside of 48 business hours of appointment time: We will gladly reschedule and no fee will be charged.

Other Charges

1. Dr. Kardong may charge for phone calls and paperwork requested that require more than 10 minutes of her time, billed in 10-minute increments of her hourly fee.  Examples include letters, forms, and consultation with other providers and treatment programs.
2. Payment:  Dr. Kardong requires payment in full at the time of each visit.  She will provide you with a monthly statement (HCFA) for tax or insurance purposes.  You may submit HCFA to your insurance company for reimbursement directly to you.  You are responsible for all charges irrespective of insurance payments you may receive that are less than her full charges.  Cash, checks, credit cards and Square are accepted for payment.
3. Cancellation Policy:  If you do not come in for your scheduled visit or, if you cancel your appointment for any reason with less than 24 hours notice, you will be charged the full cost of the session.  Insurance does not reimburse the client for these broken appointments.

Unpaid Balances

Clients who have balances which are unpaid in the prescribed time will be subject to interest of 1.5% per month.  Dr. Kardong reserves the right to collect money owed via collections agencies, small claims court or any other means allowed by law.  Non-payment for services provided by Dr. Kardong constitutes grounds for termination of treatment.