Skycloud Mental Health requires that a valid credit card be on file. By acknowledging below, you, to agree client or
responsible party for client, acknowledge that you understand and agree that:

You are an authorized user of any credit card information you provide to Skycloud Mental Health.

You will notify Skycloud Mental Health if your card becomes invalid, lost, stolen or otherwise needs to be removed from the
system.

All payment for services rendered are due at the time of the appointment.

Self-pay clients will pay $395.00 for the initial psychiatric evaluation. If the initial psychiatric evaluation goes over 60
minutes, you may be charged an additional $97.50 for every 15 minutes over the 60 minutes at the discretion of the client’s
provider. Follow appointments vary from 15 minutes to 30 minutes with a cost range of $195 for up to 30 minutes. It is your responsibility to be aware of the cost of the appointment prior to the services being rendered. Self-pay
patients are expected to pay the full amount of the appointment cost at the time of booking.

A fee of $85 is charged for the completion of forms including the following but not limited to: Disability, FMLA, LOA, and letters. Brief forms that are completed during an appointment may be eligible for a fee waiver. Payment of the form fee may be requested prior to the release of the requested forms.

There are no refunds for services rendered. You are financially responsible for all charges, whether or not: a. we
decided to proceed with treatment b. treatment is successful, for which there cannot be any guarantee.

If Skycloud Mental Health is in network with your insurance panel, you agree that we will process claims directly with your insurance company. You are responsible for the amount not covered by insurance. This is based on your individual
insurance plan and not determined by Skycloud Mental Health. Medicare/Medicaid plans are not accepted. Clients
with Medicare insurance cannot be charged as self-pay due to federal regulations. 

If client fails to cancel within 24 hours of appointment start time or does not present for appointment as scheduled, our listed no-show rates will be charged. This is considered non-refundable.

There is a 3% finance charge each month for balances more than 30 days past due. If you have not paid outstanding fees in full within 90 days, your account will be turned over to a collection agency. If your account is sent to a collection agency, they will report your past due status to a Credit Reporting Agency and you will be responsible for their fees.

There is a $30 fee for returned checks (which will also result in your credit card automatically being run for the balance due) and for credit card charge-backs that are unsubstantiated.