Description
The Documentation Wizard Financial Management Forms Package provides the foundation and organization for the financial arrangements with your client. They cover the needs of clients who use insurance and those who pay privately. They have been extensively reviewed and approved by an attorney, a bioethicist, and a billing expert.
Documentation Wizard Financial Management Forms Package includes:
- Assignment of Benefits and Billing Authorization
- Credit Card Authorization
- Receipt for Services
- Superbill
- Insurance Opt-Out Form
- Payment Log
Customization
These financial management forms can be customized for your practice needs. The areas that can be customized are highlighted in yellow for easy identification. They are not a substitute for legal or financial advice.
ASSIGNMENT of BENEFITS (AOB) and BILLING AUTHORIZATION
The AOB and Billing Authorization form is a legal agreement between the client and therapist. It gives the therapist permission to bill the insurance company directly and collect payment.
This agreement includes:
- An explanation for why a diagnosis is necessary when billing insurance
- Information about billing in network and out of network benefits
- Client’s responsibility to disclose all insurance information
- The consequences of not disclosing all insurance information
- Name of person responsible for payment
- Responsibility to pay if the insurance does not cover the service
- Timely filing and the limits of “back billing”
- Space for primary and secondary insurance information
- And more…
CREDIT CARD AUTHORIZATION FORM
Credit card authorization gets approval from the client for the therapist to use the client’s credit card to pay for therapy and other fees that may be associated with therapy.
This form collects the card information and explains:
- When, how, and under what circumstance the credit card is charged
- How the client will be notified of the charge
- The security of the credit card number
- That the therapist is not responsible for a credit card company’s potential breech of information
INVOICE FOR SERVICES
The Invoice for Services in a mental health practice is an itemized bill listing charges for each date of service and total amount owed. It is sent to the client who does not use insurance or for a service that is not covered by insurance. Because insurance is not involved, the invoice does not need to include a diagnosis. The invoice can be used as a receipt for services by marking it as paid.
SUPERBILL
A superbill is used for clients who pay privately and who get reimbursed by their insurance company. It is an itemized record that lists the services a client received. Because the bill is paid by the insurance company, it includes the client diagnosis, CPT code and modifier, POS, and session fee. The Documentation Wizard Superbill includes a “usual and customary” statement to reduce kickbacks. It’s recommended that the client submits the claims and gets reimbursement directly from the company.
INSURANCE OPT-OUT FORM
The Insurance Opt-Out form is a document that allows the client who has insurance to voluntarily choose not to use their insurance to pay for services, even if the therapist is an in-network provider. The client is responsible for paying the therapist’s full fee themselves. The Documentation Wizard Insurance Opt-Out Form explains the limits of retroactive billing should the client change their mind and decide to use their insurance at a later date.
PAYMENT LOG
The Payment Log helps the therapist keep track of who has paid for their sessions, the date paid, and by what means (cash, check, credit card, etc.). It is particularly useful to therapists who do their own billing and use paper forms or store their forms on their own computer.