Payment & Billing

Customized for your needs

We believe in making our billing process as secure and convenient as possible.

Below you will find payment options, our Credit Card Authorization form (HIPAA-compliant storage for your payment information), & our Insurance policy.

Credit Card Authorization Form

By completing this form, I hereby authorize the billing department of PsychPhilly to charge the credit card listed below for my appointments. My card will be charged at the end of each visit or within 24 hours unless a specific payment plan is chosen. Payment plans will utilize the card listed below on dates agreed upon by myself and the billing manager.

If I need to cancel or reschedule an appointment, I will provide 72 hours’ notice to the office. If I miss my appointment or cancel/reschedule with less than 72 hours’ notice, PsychPhilly will charge my card the missed appointment fee of $75.00. (barring emergency circumstances)

A valid payment/credit card is required on file for the entirety of my care at PsychPhilly.

Please complete the form below

I have read and understand the terms outlined above.

I confirm

Patient Name

First Name

Last Name

Email

Phone

(###)

###

####

Name of Cardholder

Card Number

Expiration Date

numbers only

CVV Code

Three numbers on the back of card, or for Amex 4 digit code on front of card

Billing Zip Code

Digital Signature

By typing my name below, I hereby grant the use of this card for payment purposes.

Billing Questions?

Name

First Name

Last Name

Email

Phone

(###)

###

####

What is your current relationship with Psych Philly?

Billing Inquiry

Alternately, feel free to send an email to our billing manager at drjones@hpcbilling.com with any outstanding billing & payment-related questions.

Looking for appointment rates & payment plans? Visit Rates & Insurance.

Insurance Policy

Effective April 1, 2020, PsychPhilly & its providers are not In-Network with any Insurance plans.*

*Dr. Jones is not currently in-network with any insurance plans with the exception of current patients with existing Medicare coverage. Billing Office will continue to process claims for current patients with existing Medicare coverage only. Dr. Jones is currently capped at the number of Medicare patients she sees & is unable to accept new patients with Medicare coverage at this time.

Insurance Claims & Reimbursement

Upon request, our billing office will provide a superbill/detailed receipt following your appointment(s) if you choose to submit claims (for out-of-network benefits for possible reimbursement) on your own behalf.*

*Each insurance company varies when it comes to submitting claims (e.g. faxing, emailing, submitting on insurance portal/website, etc.). To see if you qualify for out-of-network benefits and to learn about your insurance company’s claim submission process, please contact their Member Services by utilizing the Phone # found on the back of your Insurance card.