Dr. Bresler and The Bresler Center staff are here to help in all aspects of your care, including financial
arrangements. Our policy is that payment is made at the time services are rendered. Unless special
arrangements are made in advance, and an additional service fee is paid, we will not bill your insurance
company directly. This reduces our overhead expenses and helps keep our fees as low as possible.
We are open to discuss any special circumstances that affect your ability to pay for our services as they are rendered but special payment arrangements must be made prior to treatment with an agreement signed by both parties. There is a $15 service charge on all returned checks, a $15 per month service fee for direct billing your insurance company, and a 1.5% late charge per month (annual percentage rate =18%) on balances outstanding at the time of the next billing date.
ADVANCED NOTICE OF NON-COVERED SERVICES
Medicare will only pay for services that it determines to be “reasonable and necessary” under section
1862(a)(1) of the Medicare law. If Medicare determines that a particular service, although it would otherwise be covered, is not “reasonable and necessary” under Medicare program standards, Medicare will deny payment for that service. Medicare currently does not pay for acupuncture, guided imagery, and the other services we provide. In accordance with the Medicare Act, Section 1842(i), we are therefore notifying you that Medicare is likely to deny payment for the services we render. Since Medicare will not pay for our services, you hereby agree to be personally and fully responsible for payment.
Dr. Bresler is licensed both as a psychologist and as an acupuncturist by the State of California. However,
since he does not participate in any HMO or managed care organizations, many insurance companies do not provide full or even partial coverage for the services we provide. After each visit, we will provide you with forms needed to obtain reimbursement for services covered. You must contact your insurance company directly to determine the full extent of your insurance coverage.
MISSED APPOINTMENT POLICY
When you make an appointment, professional time is specially reserved to provide for your care. If you fail to appear for a scheduled appointment, or fail to give at least 24 hours notice prior to canceling your appointment, you will be charged in full for that appointment.
RECORD RELEASE AND AGREEMENT OF FINANCIAL RESPONSIBILITY
I authorize Dr. Bresler to provide copies of my medical records, billing statements, and other relevant information regarding my diagnosis and treatment to referring physicians, my insurance carrier(s) and/or my attorney. I agree that regardless of insurance or other coverage I may have, I am personally and directly responsible for all financial obligations incurred (unless my care has been pre-authorized by a Workers Compensation Insurance Carrier.