To ensure accurate claim filing, please give your most current insurance card to our receptionist to be
copied. If we are unable to verify your insurance, you will be responsible for payment at the time of service.
Hightower Behavioral Health participates with Medicare/Medicaid and most managed care plans. We will bill
your insurance company in compliance with the guidelines of our contract.
All co-payments, deductibles, and co-insurance as applicable are due at the time of
service.
Payment in full is due at the time of treatment for all private pay patients, Medicare
patients for non-assigned services (urinalysis, office visit, injections, etc.) and/or fees not
covered by your insurance.
If coverage is contingent on a referral of pre-certification, it is your responsibility to inform
us.
If you are unable to keep your appointment, we require a 24-hour cancellation notice or
your account will be charged $50.
We accept cash and the following credit cards: Visa, MasterCard, and Discover.
Any outstanding account turned over to a collection agency will be charged an additional
$35.00 fee.
I hereby authorize Hightower Behavioral Health to provide me with medical treatment. I understand
and agree that I am responsible for all fees not covered by my insurance company. I hereby
authorize the release of any medical information necessary to file a claim with my insurance
company. If my account is turned over to a collection agency, I understand and agree that I will be
responsible for any collection fees, attorney fees, court costs, or other fees incurred by me.

HIPAA NOTICE
I understand Hightower Behavioral Health follows the laws and guidelines of the HIPAA
regulations. All services and records are confidential and private to protect the patient.

If the patient is a minor, it is mandatory by HIPAA for the patient to sign a consent form to release information to a
parent or any other guardian if related to the following:
• Contraceptive Care and Counseling
• Prenatal Care
• Abortion
• Sexually Transmitted Diseases
• HIV/AIDS
• Substance Abuse
• Emergency Care