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As part of our commitment to providing excellent care, Guzman & Baker Behavioral Health Services wants to ensure our financial expectations are clearly outlined and understood. To facilitate seamless care, all patients are required to maintain a valid payment method securely on file. Any outstanding balance on your account must be paid in full prior to your next scheduled visit. If a balance remains unpaid by the time of your next appointment, that session will be rescheduled until the account is brought current.

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Patients Utilizing Insurance Benefits

The “Provisional Period” To protect you from accruing significant unexpected costs, we implement a “Provisional Period” for all new patients utilizing insurance benefits. We will schedule your Initial Intake and up to two (2) follow-up sessions pending insurance adjudication. If we have not received a processed claim (Explanation of Benefits) from your insurance carrier by the completion of your third session, we may pause scheduling future appointments until your coverage is confirmed and the first claim is paid.

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Patient Responsibility & Payment Timeliness

While we perform a courtesy verification of active coverage, you acknowledge that you are ultimately and fully financially responsible for all services rendered.
  • Standard Costs: All co-payments, co-insurance, and unmet deductibles are due within 30 days of the date your insurance claim is completely processed.
  • Overdue Balances & Notification: If an outstanding balance remains unpaid after 30 days, we will send an electronic statement detailing the amount owed. Ten (10) days following this notification, the balance will be automatically charged to your payment method on file, processed on the first day of the following calendar month.
  • Claim Denials: Should your insurance carrier deny a claim for any reason (including but not limited to lack of medical necessity, coverage termination, or plan limitations), you agree to pay the full standard self-pay rate for all services rendered.

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Self-Pay & Sliding Scale Patients

Payment Timeliness & Automatic Processing For patients electing self-pay or participating in our sliding scale program, payment in full is due at the time of service. To streamline your experience, you authorize Guzman & Baker Behavioral Health Services to automatically charge your designated payment method on file for the agreed-upon flat fee at the conclusion of the business day on which your services are rendered. Sliding Scale Eligibility Guzman & Baker Behavioral Health Services determines sliding scale eligibility utilizing the current year’s Federal Poverty Level (FPL) guidelines published by the Department of Health and Human Services (HHS), as adjusted annually based on the Consumer Price Index. Eligibility for this program is subject to annual review and income verification. If approved, your specific fee structure will be detailed in a separate written fee agreement, viewable at any time in the “Documents” section of your secure patient portal. FPL Tier Calculations:
  • Tier 1: Income at or below 138% FPL = 60% reduction ($60.00 per session)
  • Tier 2: Income between 139% and 200% FPL = 50% reduction ($75.00 per session)
  • Tier 3: Income between 201% and 300% FPL = 25% reduction ($112.50 per session)
  • ** Tier 4:** Income above 300% FPL = 0% reduction (Standard Fee applies)

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Credit Card on File & Electronic Payment Authorization

By providing your credit card, debit card, or bank account information, you consent to the following terms regarding the storage and processing of your payment credentials, in accordance with standard banking and network regulations:
  • Secure Storage: Your payment information is not stored locally at our clinic. It is securely tokenized and stored off-site by our PCI-DSS compliant third-party payment gateway.
  • Authorization for Variable & Recurring Charges: You authorize Guzman & Baker Behavioral Health Services to initiate charges to your stored payment method for co-pays, self-pay rates, sliding-scale fees, cancellation/no-show fees, and outstanding balances determined after insurance adjudication.
  • Notification of Variable Amounts (Reg E): For any post-insurance balance or charge that varies from your standard flat fee, we will provide you with written notification (via email or patient portal) detailing the amount owed at least 10 days prior  to initiating the charge.
  • Receipts: An electronic receipt will be provided via email or uploaded to your patient portal for every automated charge processed.
  • Right to Revoke: You may revoke this payment authorization at any time by providing written notice to our billing department by filling out this form at least three (3) business days before a scheduled charge.
Note: Revoking this authorization requires you to provide an alternative, valid payment method prior to your next appointment to continue receiving services.