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Phillip Baker MBA, Ed.D. 2600 Denali St, Ste 420 Anchorage, AK 99503 Phone (907) 562-2392
www.drphillipbaker.com
EXPLANATION OF SERVICES
Fee for service in Dr. Baker’s office is $225.00 per session. Payment is expected at the time of service unless prearranged. In case of insurance billing, the client is responsible for making the co-payment at the time of the office visit, and if applicable, the client’s yearly medical deductible. You must bring all necessary insurance identification cards with you and fill out necessary insurance billing forms. Dr. Baker’s billing is managed by Kristen Calahan of KC Professional Billing. The billing phone number is (907) 222-1095, and Kristen’s email is [email protected]. All necessary information needed for an insurance company to process claims will be given to Kristen for processing. If your insurance does not pay, you will be responsible for the unpaid balance. If a balance is due on your account you will receive a statement at the beginning of the month. Balances unpaid after 90+ days are subject to be sent to an outside collection agency upon Dr. Baker’s approval. Any collection fees will be the client’s responsibility to pay. Dr. Baker accepts payments via cash, check, Visa, Mastercard, and Discover card. Credit card payments may be made at www.professionalcharges.com under “make a payment” using license number AK 338, or may be given to Kristen/KC Professional Billing over the phone. All sessions last 50 minutes unless other arrangements are made with Dr. Baker. A fee of $225.00 is charged for appointments missed or canceled with less than 24 hours notice given. Missed appointment fees will be the client’s responsibility to pay, and will not be submitted to insurance policies. There will be a charge for services required beyond the therapy hour. Dr. Baker is the sole proprietor of his practice. No information regarding your contacts with Dr. Baker will be shared with anyone without your consent. I acknowledge the above conditions of service and I give my consent for treatment. _________________________ _________________________ ________________________ Client Name Signature Date
Effective 10/30/14
