Carla Velarde, MD

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Insurance Participation & Payment Acknowledgment

Insurance Participation & Payment Acknowledgment

10 Office Park way, Ste 100

Pittsford, NY 14534

Carla Velarde, MD MPH

Phone: (585) 902-0226

Fax: 1-800-749-1837

Secondary Fax: (585) 361-5252

Insurance & Billing Authorization

In consideration of services provided by Carla Velarde, M.D., M.P.H., I agree to pay any balance not covered by insurance, including copays, deductibles, coinsurance, and non-covered services. I also understand that missed appointments or appointments cancelled with less than 24 hours’ notice are subject to a late cancellation fee, which is not billable to insurance.
I authorize Carla Velarde, M.D., M.P.H., and associated billing services to release information necessary to process claims, obtain payment, and fulfill financial obligations related to my/patient’s care. All such disclosures will be made in accordance with applicable confidentiality and privacy laws.

Private Practice Insurance Policy

Dr. Carla Velarde operates an independent private psychiatric practice and is currently paneled only with Excellus/BlueCross BlueShield. She is not contracted with other commercial insurance carriers through her private practice. Participation in insurance networks through hospital systems (including Strong Memorial Hospital/URMC) does not apply to this practice. Insurance company directories may inaccurately list physicians as “in network” based on hospital affiliations.
It is the patient/guardian’s responsibility to:
- Confirm insurance participation directly with the practice prior to appointments.
- Notify the practice promptly of any insurance changes.
- Understand that information provided by an insurance carrier does not override the practice’s stated network participation status.

If insurance coverage changes to a plan not accepted by the practice, reasonable efforts will be made to support continuity of care. Patients who wish to continue treatment with Dr. Velarde may do so at the self-pay rate.The practice cannot retroactively adjust charges due to inaccurate insurance directory listings or incorrect information provided by insurers. By signing below, I acknowledge that I understand and accept these insurance and financial policies.

Credit/Debit Card Authorization

By signing below, I authorize Carla Velarde, M.D., M.P.H., to charge my credit/debit card for balances related to services rendered, including copays, deductibles, coinsurance, self-pay charges, and applicable late cancellation or missed appointment fees.I understand that:
1. Charges may be processed after appointments or once insurance claims have been adjudicated. Missed appointments or appointments cancelled with less than 24 hours’ notice are subject to a $100 late cancellation fee.
2. Receipts are available through the Charm Personal Health Portal and may also be emailed upon request.
3. It is my responsibility to notify the practice of any changes to my payment information.
4. I may revoke this authorization in writing at any time, provided there is no outstanding balance on my account.

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