HomePatient Forms & PoliciesPayment-Related Consent
Required at Intake
Payment-Related Consent
Payment responsibility, insurance billing, card-on-file, cancellation fees, home-visit fees, and refund terms.
The full Payment-Related Consent is provided as a PDF.
Use the Download PDF button above to read the complete document. You’ll review and sign this form through Jane, our practice-management system, when you schedule a visit as a new client.
If you’d like a copy of an earlier version, or if you have a question about anything in this document, email admin@bayoucitybreastfeeding.com. We won’t begin treatment until you’ve had the opportunity to review the documents and ask questions.
What this document covers
The Payment-Related Consent describes how visits are paid for: your responsibility for charges that are not covered by insurance, how insurance billing works, what we keep on file (including card-on-file authorization), our cancellation and late-arrival fees, additional fees that apply to home visits, and how refunds are processed. Fees for clinical services are governed by this consent, not by the website Terms.
How it fits with the other forms
This is one of the four core intake documents (along with the Notice of Privacy Practices, the Good Faith Estimate, and the Payment-Related Consent), plus the Master Intake Acknowledgment that confirms you have reviewed all four. New clients receive these through Jane, our practice-management system, when an appointment is scheduled.
Questions before you sign?
Email admin@bayoucitybreastfeeding.com or call (281) 305-0411. We’re happy to walk through any section with you before your first visit.
Ready to schedule?
When you book a visit, Jane sends you the intake documents and the consent for the service you’re scheduling. Request Appointment or call (281) 305-0411.