(770)436-9700














(770)436-9700
 

  
 

 

 

 CUMBERLAND PSYCHIATRIC GROUP
CPG

Roswell   ·   Smyrna-Vinings   ·    Decatur		  
 
 

Financial Policies

1.   Co-payments and/or co-insurance are due at the time of service.  Due to legal considerations this policy must be applied uniformly.

2.   Insurance requires pre-authorization. Payment in full is expected without proof of authorization.  The appropriate payment is required at each visit, if the patient is a minor; payment is still required regardless of the relationship of the adult to the minor. In the case of children of divorced parents, payment is due at the time of service regardless of the terms of the divorce decree.

3.   C.P.G. will bill insurance for the patient.

  
 
     ● Benefits will be assigned.
   
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The patient authorizes C.P.G. to release any necessary information to process the insurance claims.
   
     ●

Charges not paid by your insurance company within 120 days will become the patient’s responsibility.
 
 
 

4.  Physician fees for inpatient services are billed separately from the hospital charges.
 

5.  Administrative charges:
 

  
 
    ● Prescription refill/Consultation (Including calls from local and Mail 0rder Pharmacies) $25.00
     
    ● Non-Formulary Drug Requests (Prior Authorization) $15.00
     
    ● Missed appointment without notification by noon of the prior business day $60.00 
    ● Routine paperwork, (e.g. requests for medical records) $50.00(+)
     
    ● Extensive paperwork $75.00(+)
     
    ● Returned check $30.00
 
 

Please note: If the information you provide is not correct and kept current the balance becomes your responsibility at CPG’s fee schedule.  We realize that emergencies do arise and may affect timely payment of your account.  If such extreme cases do occur, please contact us promptly for assistance in the management of your account.

If it becomes necessary to collect any sum due through an attorney or collection agency, then the guarantor agrees to pay all reasonable costs of collection, including attorney’s fees, whether the suit is filed or not.

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Patient signature


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Guarantor signature  


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Date

 

  
 

A copy of this document may be downloaded for printing.  Once fully executed it should be returned to our office via fax at:  (678) 736-7308


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