• Billing Information and Agreement

  • Billing Information and Agreement

  • Insurance Information

  • Failure to pay outstanding balances will lead to Collections, which will increase the amount owed.

    Please be advised that there will be a $35.00 Service Charge for all returned checks. A 24-hour notice of cancellation is required for all appointments. Failure to provide a 24-hour cancellation notice will result in a charge for the full payment amount for your missed appointment. We will be unable to reschedule you for another appointment until the "no show fee" has been paid in full.

    Your signature authorizes Mosaic Psychological Services to charge your credit care for any outstanding balances not covered by insurance. Please notify us if there are any changes to your existing coverage, failure to notify may result in you being responsible for the full amount.

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