In compliance with the No Surprises Act that went into effect January 1, 2022, I am required to notify all healthcare consumers of your Federal rights and protections against “surprise billing”. This Act requires that I notify you of your federally protected rights to receive a notification when services are rendered by a non-participating provider and provide options to receive care from an in-network provider if we are not in network. Read more: https://www.cms.gov/nosurprises

Payment for therapy services is due before or at the time of your session.

Magnolia Therapy Center reserves the right to potentially cancel your appointment or suspend the provision of therapy services due to an outstanding balance until the balance is paid.

A $10.00 administrative fee may apply to any balances extending beyond 30 days.

All clients are advised that a $50.00 fee may be charged for any missed appointments or appointments that are canceled less than 24 hours in advance.

Fee Structure:

The fee for medical records requests is set at $1.00 per page. This fee covers the cost of retrieving, copying, and processing the requested medical records. The total fee for the requested medical records will be calculated based on the number of pages at the established rate of $1.00 per page.

Payment Due Before Release:

Payment is required in full before medical records are released to the requesting party.

Acceptable forms of payment include cash or credit card.

Payment Submission:

Payment should be submitted along with the completed Medical Records Request Form.

Credit card payments can be made over the phone or in person.

Prior Balances:

Any outstanding balances from previous services must be paid in full before processing a new medical records request.

Records Release:

Upon receipt of payment, the medical records will be promptly processed and released to the requesting party.

Expedited Requests:

Expedited requests may be accommodated with an additional fee. Please inquire about expedited processing options at the time of the request.

All clients are advised that a $50.00 fee may be charged for any missed appointments or appointments that are canceled less than 24 hours in advance.