ALQUIMEDEZ MENTAL HEALTH COUNSELING
FINANCIAL RESPONSIBILITY AGREEMENT
Version 2026.1 | English
Applies to services provided in Arizona, Connecticut, Florida, Indiana, New Jersey, New York, and Pennsylvania, subject to applicable law and insurance requirements.
1. Purpose
This agreement explains Alquimedez Mental Health Counseling’s financial policies. It is separate from consent to treatment, acknowledgment of the Patient Bill of Rights, and authorization to store or charge a payment card.
Signing this agreement acknowledges these policies. It does not authorize unrestricted charges, waive patient protection, or make you responsible for amounts that cannot lawfully be collected from you.
2. Insurance information and verification
Please provide accurate, current insurance information, including images of the front and back of your insurance card. Notify us promptly of changes to coverage, the policyholder, other insurance, or information needed to submit claims.
Alquimedez and its billing team will verify benefits when possible. Verification, prior authorization, and quoted copayment are not guarantees of payment. Coverage may depend on your plan, the treatment provider, service, location, and date of service.
You may contact your insurer to understand your benefits. Our billing team can assist with questions about coverage and claims.
3. Your financial responsibility
You are responsible only for amounts properly assigned to you under applicable law and your insurance plan, such as permitted copayments, deductibles, and coinsurance.
An insurance denial does not automatically make the denied amount your responsibility. Alquimedez will review the denial, contractual requirements, and applicable protections before billing you. We will not transfer prohibited contractual adjustments or provider-responsibility amounts to you.
Noncovered or out-of-network services will be discussed in advance when reasonably possible. Any required notice or separate agreement will be obtained before patient liability is established.
4. Fees, estimates, and self-pay services
Before you agree to a self-pay or separately priced service, we will explain the applicable fee and payment terms. This agreement does not establish a specific treatment price.
Uninsured patients and patients choosing not to use insurance will receive a Good Faith Estimate when required by federal law. An estimate is not a guarantee of the final cost. Applicable billing-dispute rights remain available.
Changes to practice fees will be communicated before they apply to future services.
5. Payment timing
Permitted copayments and agreed self-pay amounts are generally requested at the time of the visit, subject to applicable law. Additional patient responsibility may be billed after insurance processing.
Statements will identify the amount due and payment instructions. If you believe a balance is incorrect or cannot pay as requested, contact customer service or billing promptly to request review or discuss available arrangements.
6. Cancellations and missed appointments
Please cancel or reschedule at least 24 hours before your appointment through an approved Alquimedez scheduled channel.
A $25.00 no-show fee may apply when you do not attend a scheduled appointment and have not canceled it before its scheduled start time. This agreement does not establish a separate late-cancellation fee.
The fee applies only when permitted by law and your insurance requirements, after you have received this policy. It is not billed to insurance as a clinical service.
No fee will be assessed for a provider cancellation, duplicate or incorrectly recorded appointment, or a verified practice-related technical failure. Emergencies, hospitalization, disability-related access barriers, and other circumstances may be reviewed individually.
No-show fees will not be charged to Medicaid beneficiaries where prohibited. Other payer restrictions and protections will also apply. You may request review before collecting a disputed fee.
7. Cards on file
Where permitted, Alquimedez may request a securely stored payment method. Card storage and any future charges require a separate Card on File & Payment Authorization Form. Signing this agreement alone does not authorize a card charge.
Do not send full card numbers or security codes by email, text message, or chatbot. Use the approved secure payment interface.
Connecticut: Providing a payment method to keep on file is voluntary and will not be required as a condition of receiving care. Declining card storage does not eliminate responsibility for legitimately owed amounts, which may be paid through another accepted method.
8. New York payment consent
We document consent to treatment, acknowledgment of financial policies, and consent to payment separately.
For New York patients, this agreement is an acknowledgment of financial policies and is not blanket advance consent to pay for future healthcare services. Alquimedez will follow applicable New York requirements and implementation guidance, including obtaining additional payment consent after services and discussion of costs when required.
9. Billing support, disputes, and refunds
Alquimedez’s authorized billing partner, Stars PMB, may assist with insurance claims, statements, and payment questions under applicable privacy safeguards.
You may request an itemized explanation, report an error, or dispute a charge. Disputed amounts will be reviewed before further collection of those amounts. Confirmed that overpayments will be refunded or otherwise resolved as required by law and payer rules. Signing this agreement alone does not authorize any collection costs, penalties, or interest.
10. Representatives and language
A representative must identify their relationship and authority to sign. Signing as a parent, guardian, or representative does not, by itself, create personal financial liability beyond what applicable law or a separate valid agreement allows.
You may receive this agreement in English or Spanish, ask questions before signing, and receive a copy of the signed document.
Acknowledgment
I acknowledge that I have received and reviewed this agreement and have had an opportunity to ask questions. I understand that any financial responsibility is subject to applicable law and insurance requirements. This signature does not authorize automatic card charges or waive my rights.
Document language: English
Document version: 2026.1