Financial Responsibility Policy

Last Updated: June 25, 2026

We are pleased that you have chosen Haven Health of California, P.C. (“Haven Health”) as your health care provider. To ensure transparency and avoid any misunderstandings regarding the cost of your care, please review this Financial Responsibility Policy carefully before receiving services.

ASSIGNMENT OF BENEFITS AND RIGHT TO PAYMENT

By signing our patient intake and consent forms, you irrevocably assign to Haven Health all of your rights and benefits and any other interests that you have in any medical insurance plan, health benefit plan, indemnity plan, trust, fund, or other source of payment for healthcare services in connection with the medical services provided by Haven Health, its employees, and agents.

You authorize Haven Health to bill your insurance carrier on your behalf and to receive payment directly from your insurer for covered services. You instruct your insurance company to pay Haven Health directly for the professional or medical expense benefits payable to you. If your current policy prohibits direct payment to Haven Health, you instruct your insurance company to make the check payable to you and mail it directly to Haven Health at:

Haven Health of California, P.C.

6221 Wilshire Blvd, #216

Los Angeles, CA 90048

In the event your insurance payer pays you directly, you agree to immediately remit such amounts to Haven Health. This assignment will remain in place until revoked by you in writing.

INSURANCE PARTICIPATION

Haven Health participates with certain commercial insurance plans. Except for those active participating plans, Haven Health does not participate in any other commercial insurance plans.

Your insurance payer may pay less than the actual bill for services. You acknowledge that you are still responsible for paying Haven Health for any and all amounts not covered by your insurance payer, including non-covered charges and all copayments, coinsurance, and deductibles. Copayments, deductibles, and any other cost-sharing amounts are due at the time of service.

It is your responsibility to provide accurate and current insurance information at each visit. If incorrect insurance information is provided and a claim is denied as a result, you will be responsible for the full balance. Haven Health cannot guarantee coverage or benefits and encourages you to verify your benefits with your insurance carrier prior to your appointment. If you have secondary insurance coverage, Haven Health will, as a courtesy, file claims with your secondary insurer after your primary insurer has processed the claim. You remain responsible for any balance not covered by either insurer.

You understand that if your insurance plan requires a referral, you are responsible for obtaining one prior to your appointment. If a required referral or prior authorization is not obtained, you will be personally responsible for all charges associated with those services. Haven Health will make reasonable efforts to assist in this process but cannot guarantee that your insurer will authorize or cover any particular service.

MEDICARE AND MEDICARE-RELATED INSURANCE

Haven Health participates with Medicare and Medicare Advantage plans. We will bill Medicare as the primary payer for covered services. For services that may not be covered by Medicare, Haven Health will provide you with an Advance Beneficiary Notice of Non-Coverage (“ABN”) prior to providing that service. By signing the ABN, you acknowledge that you have been informed that Medicare may not cover the service and that you agree to be personally responsible for the cost if Medicare denies the claim. If you do not sign the ABN prior to receiving a non-covered service, Haven Health may be unable to bill you for that service. You remain responsible for all applicable Medicare cost-sharing amounts, including deductibles, coinsurance, and copayments, which are due at the time of service.

MEDICAID AND MEDI-CAL

Haven Health is not enrolled in Medicaid or Medi-Cal and is therefore unable to see patients with these benefits, even on a self-pay basis. It is your responsibility to disclose whether you are receiving Medicaid or Medi-Cal benefits before receiving care from Haven Health. Failure to disclose your Medicaid or Medi-Cal enrollment may result in discharge from our practice to protect both you and Haven Health from compliance issues under these programs.

SELF-PAY PATIENTS

If you do not have insurance coverage or do not have insurance through one of our participating plans, you will be treated as a self-pay patient. If you have insurance through a plan that Haven Health accepts but elect not to use your insurance benefits for non-covered services, you may be treated as a self-pay patient for those specific services only, subject to the terms of Haven Health's agreement with your insurer. Note: If you are enrolled in Medicaid or Medi-Cal, you are not eligible for self-pay services; please refer to the Medicaid and Medi-Cal section of this Policy. By signing our patient intake and consent forms as a self-pay patient, you acknowledge that: (1) you do not have health insurance through Medicare or an insurance plan that Haven Health accepts; or (2) you have health insurance that Haven Health does not accept and you do not want to use any insurance benefit for Haven Health services. Self-pay patients are required to pay for services in full at the time of service. If you are a Medicare or Medicare Advantage beneficiary, you may not elect self-pay status for services that are covered by Medicare; please refer to the Medicare section of this Policy. If you are enrolled in Medicaid or Medi-Cal, you are not eligible for self-pay services from Haven Health; please refer to the Medicaid and Medi-Cal section of this Policy. Please speak with our billing team prior to your appointment to discuss applicable fees.

Haven Health has provided you with the applicable charges in advance for the services you have requested. By receiving services, you agree to pay these charges in full and accept full financial responsibility for payment.

AUTHORIZED PAYMENT PROCESS

Haven Health, directly or through its third-party payments vendor, will provide you an invoice and payment authorization form (“Authorized Payment Method”) to complete. You will be charged for applicable cost-sharing amounts and any non-covered balances at the time of your visit. We accept most common credit card networks including Visa, Discover, MasterCard, and American Express. We accept debit cards and FSA/HSA cards, so long as they are through the above networks.

You understand and acknowledge that when you provide an Authorized Payment Method, Haven Health (or its third-party payments vendor) will attempt to verify the information provided by processing an authorization hold on your account. Haven Health will not charge you in connection with this authorization hold, but your available balance or credit limit may be temporarily reduced.

Haven Health reserves the right to update your account information if your payment card issuer provides updated card details, and will use such updated information to process future payments. If your bank or card issuer reverses a charge, Haven Health reserves the right to bill your account directly and seek payment by another method. Haven Health reserves the right to change its fees and to institute charges for additional services at any time. If you believe you have been billed incorrectly, you must contact Haven Health no later than thirty (30) days after such charge has been processed to receive an adjustment or credit. Billing inquiries should be directed to help@havenhealth.care. In the event your Authorized Payment Method is declined for any reason, Haven Health will contact you and request that you update your Authorized Payment Method immediately.

Your statements will be available via your patient portal and will also be emailed to you. If you have any questions about this process, please contact us.

NO-SHOW AND CANCELLATION POLICY

We ask that you cancel or reschedule your appointment at least 24 hours in advance. A fee of $150 will be charged for any no-show or late cancellation without sufficient advance notice. Two consecutive late cancellations or no-shows may result in discharge from our practice.

COLLECTIONS AND RETURNED PAYMENTS

Accounts with balances outstanding for more than ninety (90) days may be referred to an outside collection agency. In the event any collection action is necessary, you agree to pay all expenses associated with such action, including collection agency fees and reasonable attorneys’ fees. Haven Health reserves the right to discharge patients with delinquent accounts from the practice.

A fee of $35.00 will be assessed for any payment returned for insufficient funds or any other reason. Returned payment fees must be paid by cash, money order, or credit card.

DURATION AND REVOCATION OF AUTHORIZATION

This authorization is valid until you are no longer a patient of Haven Health, within five (5) years from the date indicated on your intake form, or as required by applicable state law, whichever is earlier. You understand that you have the right to revoke this authorization, in writing, at any time by sending written notification to Haven Health at help@havenhealth.care.

Thank you for choosing Haven Health.