Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay for services, you are ultimately responsible to pay for services. Payment that is not made at the time of a session is expected within 30 days. I am happy to work with patients to arrange for payment plans if that becomes necessary. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action becomes necessary, the costs will be included in the claim. In most collection situations, the only information I release regarding treatment is the client’s name, the nature of the services provided (i.e. individual psychotherapy), and the amount due. Initials (of Individual, couple or family) 3 In order for us to set realistic goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefit, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I am required to relate additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases). This information will become part of the insurance company’s files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical databank. I will provide you with a copy of any report I submit, if you request it. Once we have all the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatment. It is important to remember that you always have the right to pay for my services yourself to avoid these problems that compromise your full confidentiality.
Appears in 1 contract
Sources: Psychotherapy Services Agreement
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangementotherwise. Payment schedules Any payment schedule for other professional services will be agreed established before initiating the service. Your signature below also acknowledges your understanding that Dr. ▇▇▇▇ is ethically prohibited from billing health insurance companies for any forensic evaluation or forensic consultation. With the exception of SoonerCare (Medicaid) for children I do not typically file insurance for clients. At the end of each session I will provide a Patient Service Record (PSR) that contains all the information necessary for you to when they are requestedfile your own insurance. If your insurer determines that they will not pay for services, you are ultimately responsible to pay for services. Payment that is not made at the time of a session is expected within 30 days. I am happy to work with patients to arrange for payment plans if that becomes necessary. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action becomes necessary, the costs will be included in the claim. In most collection situations, the only information I release regarding treatment is the client’s name, the nature of the services provided (i.e. individual psychotherapy), and the amount due. Initials (of Individual, couple or family) 3 In order for us to set realistic goals and priorities, it It is important to evaluate what resources understand that your insurance plan may not cover out-of-network providers or may reimburse you have available for my services at a substantially reduced rate. You are agreeing here to pay be responsible for your treatmentthe fee we establish. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in any questions about your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call should ask your plan administrator. Of course, I will provide If you with whatever information I can based on my experience and will be happy choose to help you in understanding the information you receive request reimbursement from your insurance company. If it is necessary to clarify benefitcompany for your treatment expenses, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most your contract with your health insurance companies require you company likely requires that I provide it with information about my services to authorize me you. I am usually required to provide them with a clinical diagnosis. Sometimes I am required to relate provide additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases)Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company’s company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. Once we have all the By signing this Agreement, you agree that I can provide requested information about to your carrier if you choose to request reimbursement for fees paid to me by you personally or through your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatmentplan. It is important to remember that you always have the right to pay for my services yourself to avoid these problems that compromise your full confidentialityTHIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Appears in 1 contract
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise otherwise. If any outstanding balances are not paid at the time of service, including fees, copays, missed appointments, charges for miscellaneous services (i.e., letters, document requests, etc.) or unless if your insurance plan does not pay for the service rendered, your credit card on file will be automatically charged at the end of the business day. We require that you have insurance coverage that requires another arrangementsubmit credit card information to be securely stored in the client portal for these potential outstanding balances before your first appointment. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay for servicesPayments can be made in cash, you are ultimately responsible check or credit card. In circumstances of unusual financial hardship, we may be willing to pay for services. Payment that is not made at the time of negotiate a session is expected within 30 days. I am happy to work with patients to arrange for fee adjustment or payment plans if that becomes necessaryinstallment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I we have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action becomes is necessary, the costs you will be included in the claimresponsible for all costs of collection, including reasonable attorneys’ fees. In most collection situations, the only information I we release regarding a patient’s treatment is the client’s his/her name, the nature of the services provided (i.e. individual psychotherapy)provided, and the amount due. Initials (of Individual, couple The Center for Family and Behavioral Health does not participate with any public or family) 3 private insurance plans. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually may provide some coverage for mental health and/or health and behavior treatment. I Most insurance policies (but usually not HMOs) have "out-of-network" benefit plans which will fill out forms and provide you with whatever assistance I can in helping you receive benefits reimburse patients directly for some portion of our fees. You are encouraged to which you are entitled; however, you (not contact your insurance company) are responsible company to determine if it provides benefits for full payment of my fees. It is important that you find out exactly what out-of-network outpatient mental health services treatment. Carefully read the portions of your insurance policy covers. You should carefully read the section in your insurance that describe coverage booklet that describes for mental health services. If you have questions about the coverage, call your plan administrator. Of courseYou are responsible for determining what your insurance will cover, I including relevant deductibles and requirements for pre-authorization if needed. It is very important that you find out exactly what Mental Health services your insurance policy covers. As out-of-network providers, we do not process claims or deal with collections from insurers. However, at your request, the Center for Family and Behavioral Health clinician will provide you with whatever information I itemized statements which document your diagnosis, payments and CPT codes so that you can based on my experience and will be happy to help you in understanding the information you receive from file your own claims. You (not your insurance company. If it is necessary to clarify benefit, I will be willing to call the company on your behalf. Due to the rising costs ) are responsible for full payment of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapyour fees.) You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I am required to relate additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases). This information will become part of the insurance company’s files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical databank. I will provide you with a copy of any report I submit, if you request it. Once we have all the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatment. It is important to remember that you always have the right to pay for my services yourself to avoid these problems that compromise your full confidentiality.
Appears in 1 contract
Sources: Outpatient Psychotherapy Services Consent Form/Contract
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they Returned checks will not pay be assessed a $25 administrative fee for services, you are ultimately responsible to pay for services. Payment that is not made at the time of a session is expected within 30 days. I am happy to work with patients to arrange for payment plans if that becomes necessaryeach occurrence. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using a legal means to secure the paymentpayment unless otherwise prohibited by your insurance carrier. This may involve hiring a collection agency or going through small claims court. If such legal action becomes necessary, the costs court which will be included in the claimrequire me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is the client’s his/her name, the nature of the services provided (i.e. individual psychotherapy)provided, and the amount due. Initials (of IndividualIf such legal action is necessary, couple or familyits costs will be included in the claim.) 3 In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. If I am an in-network provider for your insurance carrier, I will bill in accordance with their policy less any applicable co-payments. If we are not an in-network provider for your insurance carrier, I will not fill out forms and nor will I submit your requests to your insurance company unless agreed upon at the initiation of services. I will provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my the fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefitclear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients patients feel that they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most your contract with your health insurance companies require you company requires that I provide it with information relevant to authorize me the services that I provide to you. I am required to provide them with a clinical diagnosis. Sometimes I am required to relate provide additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases)Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company’s company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we I have all of the information about your insurance coverage, we I will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatmentsessions. It is important to remember that you always have the right to pay for my our services yourself to avoid these the problems that compromise your full confidentialitydescribed above (unless prohibited by contract).
Appears in 1 contract
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay for services, you are ultimately responsible to pay for services. Payment that is not made at the time In circumstances of a session is expected within 30 days. I am happy to work with patients to arrange for payment plans if that becomes necessary. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed uponunusual financial hardship, I have the option of using may be willing to negotiate a legal means to secure the paymentfee adjustment or payment installment plan. This may involve hiring a collection agency or going through small claims court. If such legal action becomes necessary, the costs will be included in the claim. In most collection situations, the only information I release regarding treatment is the client’s name, the nature of the services provided (i.e. individual psychotherapy), and the amount due. Initials (of Individual, couple or family) 3 In order for us to set realistic treatment goals and priorities, it is important to evaluate what the resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (you, not your insurance company) , are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefit, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most your contract with your health insurance companies require you to authorize me to company requires that I provide them with information relevant to the services provided you. I am required to provide a clinical diagnosis. Sometimes I am required to relate provide additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases)Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company’s company files and will probably be stored in a computer. Though all insurance companies claim By signing this Agreement, you agree that I can provide requested information to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical databank. I will provide you with a copy of any report I submit, if you request ityour carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatmentsessions. It is important to remember that you always have the right to pay for my services yourself to avoid these the problems that compromise your full confidentiality.described above, unless prohibited by contract. Rev. 02/20
Appears in 1 contract
Billing and Payments. You will be expected to pay for each session at the time it is held, held unless we agree otherwise or unless otherwise. If I am billing your insurance, you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay for services, you are ultimately responsible expected to pay for servicesyour deductible, co-insurance, and/or co-pay at each session. Payment that is not made at the time of a session is expected within 30 days. I am happy to work with patients to arrange for payment plans if that becomes necessaryCo-pay and co-insurance amounts vary depending upon your insurance policy. If your account has not been paid for more than 60 30 days and arrangements for payment have not been agreed upon, I may assess a 5% late fee per month. I also have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action becomes necessary, the costs will be included in the claim. In most collection situations, the only information I would release regarding a patient’s treatment is the client’s his/her name, the nature of the services provided (i.e. individual psychotherapy)provided, and the amount due. Initials (of IndividualIf such legal action is necessary, couple or family) 3 In order for its costs will be included in the claim. For us to set realistic goals and prioritiestreatment goals, it is important to we must evaluate what your available resources you have available to pay for your treatment. If you have a health insurance policyinsurance, it will usually provide some coverage for mental health treatmenttreatment coverage. I will fill out forms bill your primary insurance carrier if possible and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; . Please keep in mind, however, you (that you, not your insurance company) , are responsible for full payment of my fees. It is very important that you we find out exactly what mental health services your insurance policy covers, and what deductibles or co-pay/co-insurance fees are considered your responsibility. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your our plan administratoradministrator or customer service number. Of course, I will provide you with whatever information I can based on my experience and experience, will be happy to help you in understanding understand the information you receive from your insurance company. If it is necessary to clarify benefit, I and if necessary, will be willing to call the company on your behalf. Due behalf to the rising costs of health care, insurance benefits have increasingly become more complexascertain coverage. It is sometimes may be difficult to determine exactly how much mental health coverage is available. available in advance because many “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek and require approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most health insurance companies require you that I furnish information about the services that I provide to authorize me to provide them with you, including a clinical diagnosis. Sometimes In addition, some plans require that I am required to relate provide additional clinical information such as treatment plans or summaries. In such situations, or copies of I will discuss your entire record (in rare cases)insurance company’s requirements with you, and make every effort to release only the minimum information about you that is necessary. This information will become becomes part of the insurance company’s files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidentialcompany files, over which I have no control over what they do with it once it is in their handscontrol. In some cases, they may share the information with a national medical databankinformation data banks. I will provide you with a copy of any report I submit, if you request it. By signing this agreement, you agree that I can provide requested information to your insurance plan if I am billing your insurance for your psychotherapy services. Once we have all the information know about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatmentyou. It is important While much can be accomplished in time-limited or short-term therapy, some patients choose to remember that you continue psychotherapy after their insurance benefits have ended. I am happy to discuss self-pay arrangements with you. You always have the right to choose to pay for my services yourself without using insurance. Often I am not immediately available by telephone. When I am in my office I do not answer the phone when I am with a patient. My telephone (▇▇▇-▇▇▇-▇▇▇▇) is answered by a confidential voicemail that I monitor until 9pm Monday through Friday. I will make every effort to return your call on the same business day, and on the following business day for calls received on weekends and holidays. If you are difficult to reach, please inform me of times when you will be available. When I am unavailable for an extended period of time, I will provide you with the name of a colleague to contact if necessary. In ca se of an emergency, if you are unable to reach me and feel that you cannot wait for me to return your call, contact your physician, go to the nearest emergency room or psychiatric emergency service, or call 911. If you are seeing me for adjunctive EMDR, please contact your primary therapist for emergencies that may arise. If you feel you need greater emergency phone availability, I can provide you with names of other mental health professionals or clinics that provide 24-hour telephone crisis coverage. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can release information about your treatment to others only if you sign a written authorization form that meets certain legal requirements defined by HIPAA. Other situations require only your written, advance consent. Your signature on this Agreement provides consent for these activities, as follows: • Consultation with other health and mental health professionals regarding my practice. During consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record. • Consultation with other psychotherapy or psychopharmacology professionals that you currently see to coordinate your care. The other professionals are also legally bound to keep the information confidential. If you have any concerns about this consultation, please discuss them with me. • Disclosures required by health insurers or to collect overdue fees, discussed elsewhere in this Agreement In some situations I am permitted or required to disclose information without your consent or authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation or disability claim, I must, upon appropriate request, provide appropriate information, including a copy of the patient’s record, to the patient’s employer, the insurer, or the Department of Worker’s Compensation. There are some situations in which I am legally obligated to take actions when I believe my actions are necessary to attempt to protect others from harm. In these situations, I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice. • If I have reason to believe that a child under age 18 is suffering from physical, emotional, or sexual abuse, or from neglect (including malnutrition), the law requires that I file a report with the Connecticut Department of Social Services. Once such a report is filed, I may be required to provide additional information. • If I have reason to believe an elderly or handicapped individual is suffering from abuse, the law requires that I report this to the Connecticut Protective Services for the Elderly. Once such a report is filed, I may be required to provide additional information. • If a patient communicates an immediate threat of serious physical harm to an identifiable victim, or if a patient has a history of violence and the apparent intent and ability to carry out such a threat of serious physical harm, I may be required to take protective actions. These may include notifying the potential victim, contacting the police, and/or seeking hospitalization for the patient. • If a patient threatens to harm him/herself, I may be obligated to seek evaluation and/hospitalization for him/her, or to contact family members or others who can help provide protection. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will attempt to limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. You should be aware that, pursuant to HIPPA, I have a Clinical Record (CR) for you. It includes information about your reasons for seeking therapy, a description of your problems and their impact on your life, your medical and social history, your treatment history, your diagnosis, our treatment goals, and your progress towards these goals. In addition, the CR includes any past treatment records that compromise I received from other providers, reports of a any professional consultations, and any reports that have been sent to anyone, including reports to your full confidentialityinsurance carrier. If you request in writing, you have the right to examine and/or receive a copy of your CR. Because these are professional records that can be misinterpreted and/or be upsetting to untrained readers, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In situations where I believe that access to your records would adversely affect your well-being, you have a right to a summary and to have your record sent to another mental health provider or your attorney. If I refuse your request for access to your records, you have a right to request a review of my refusal, which I will discuss with you upon your request. HIPAA provides you with several new or expanded rights with regard to your CR and disclosures of PHI. These include the right to: • Request that I amend your record • Request restrictions on what information from your CR is disclosed to others • Ask for an accounting of most PHI disclosures that you have not consented to nor authorized • Determine the location to which PHI disclosures are sent • Have any complaints you make about my policies and procedures recorded in your records, and • Receive a paper copy of this Agreement, the “Notice of Policies and Practices to Protect the Privacy of Your Health Information”, and information about my privacy policies and procedures. I am happy to discuss any of these rights with you.
Appears in 1 contract
Sources: Patient Services Agreement
Billing and Payments. You will be are expected to pay in-full for each session at the time it is heldheld or prior to the group sessions, unless we agree otherwise agreed upon in writing, or unless if using In-Network insurance, in which case you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay responsible for services, you are ultimately responsible to pay for services. Payment that is not made any known copay and coinsurance at the time of service. For accounts that have a session is expected within 30 days. I am happy to work with patients to arrange balance, bills are sent at the end of each month for payment plans if that becomes necessarymonth, using an electronic billing service. If your account has not been paid for more than 60 90 days and arrangements for payment have not been agreed upon, I have you may be charged an interest rate of up to 2% per month, at the beginning of each month, on the remaining balance. Please also note that bounced checks will require a $30 fee in addition to the original payment amount. Center for Valued Living, PLLC has the option of using a legal means to secure the overdue payment. This may involve hiring a collection agency or going through small claims court. If such legal action becomes necessary, the costs which will be included in the claimrequire me to legally disclose otherwise confidential information. In most collection situations, the only information I release released regarding a patient’s treatment is the client’s his/her name, the nature of the services provided (i.e. individual psychotherapy)provided, and the amount due. Initials (If such collection and/or legal action are necessary, you will be responsible for the full amount of Individualthese costs and these costs will be included in the claim. Currently, couple or family) 3 In order the Center for us Valued Living, PLLC accepts payment directly from select insurance companies. Please inquire with your insurance company if we are an In-Network provider with your specific plan. You may choose to set realistic goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health use Out-of-Network insurance policy, it will usually provide some coverage for services if your insurance benefits include Out-of-Network mental health treatmentcoverage. I will fill out forms and provide Although you with whatever assistance I can in helping you receive benefits may elect to which you are entitled; howeveruse Out-of-Network insurance coverage, you please be aware that YOU (not your insurance company) are responsible for full payment of my feesfees at the time of service. If you chose to use insurance, I can provide a detailed receipt for you to submit to your insurance company as a complementary service. If you have health insurance, it will usually provide some coverage for mental health treatment and may or may not include group treatment, specifically. It is very important that you find out exactly what mental health services your insurance policy coverscovers through Out-of- Network benefits, the process you need to follow to obtain those benefits and the amount of your deductibles or other obligations BEFORE you begin treatment, or whenever your insurance company and/or policy changes. It is your responsibility to find out this information before beginning treatment. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefit, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I am required to relate additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases). This information will become part of the insurance company’s files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical databank. I will provide you with a copy of any report I submit, if you request it. Once we have all the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatment. It is important to remember that you always have the right to pay for my services yourself to avoid these problems that compromise your full confidentiality.ask:
Appears in 1 contract
Sources: Therapist Patient Services Agreement
Billing and Payments. I am a fee for service provider. I do not file insurance claims for you, but upon request, I will provide you with all of the information that you should need to make a claim. You may receive reimbursement from your insurance provider if you have “out of network” benefits. This has been successful for a number of my patients. Of course, plans vary, particularly with regard to mental health coverage, and you will need to discuss reimbursement with your insurance provider if you would like to pursue this option. I collect full payment at the time of your visit and then your insurance company will reimburse you directly after you submit your claim. Also, if you plan on billing your insurance for reimbursement of your visit, you will need to obtain a prescription from your physician prior to your first appointment. If you do not plan on billing insurance, you do not need a prescription. Again, I will give you the paperwork and medical diagnosis codes for you to send to your insurance company. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangementheld at the beginning of your session. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay for servicesIn circumstances of unusual financial hardship, you are ultimately responsible I may be willing to pay for services. Payment that is not made at the time of negotiate a session is expected within 30 days. I am happy to work with patients to arrange for fee adjustment or payment plans if that becomes necessaryinstallment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action becomes is necessary, the its costs will be included in the claim. In most collection situations, the only information I release regarding a patient’s treatment is the client’s his/her name, the nature of the services provided (i.e. individual psychotherapy)provided, and the amount due. Initials (of Individual, couple or family) 3 In order for us to set realistic goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefit, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I am required have to relate provide additional clinical information such as treatment plans or summaries, or copies of your the entire record (in rare cases). This information will become part of the insurance company’s company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. Once we have all Contacting Me.I am often not immediately available by telephone. While I am usually in my office between 9 AM and 5 PM, Monday through Friday I will not answer the information about phone when I am with a patient. I will make every effort to return your insurance coveragecall on the same day you make it, we will discuss what we can expect to accomplish with the benefits that exception of weekends and holidays. If you are available difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and what will happen if they run out before you feel ready to end your treatment. It is important to remember that you always have can’t wait for me to return your call, contact your family physician or the right nearest emergency room and ask for the psychologist [psychiatrist] on call. You may also call the EMPACT psychological crisis line at ▇▇▇-▇▇▇-▇▇▇▇. If I will be unavailable for an extended time, I will provide you with the name of a colleague to pay for my services yourself to avoid these problems that compromise your full confidentialitycontact, if necessary.
Appears in 1 contract
Sources: Professional Policy and Procedure Agreement & Patient’s Informed Consent of Practice
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay for services, you are ultimately responsible to pay for services. Payment that is not made at the time of a session is expected within 30 days. I am happy to work with patients to arrange for payment plans if that becomes necessaryavailable upon request. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I we have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims courtcourt which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action becomes is necessary, the its costs will be included in the claim. In most collection situations, the only information I release regarding treatment is the client’s name, the nature of the services provided (i.e. individual psychotherapy), and the amount due. Initials (of Individual, couple or family) 3 In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health Insurance policies vary greatly and we cannot guarantee that your policy will cover psychotherapy or psychological testing. We do not participate in managed care or submit insurance policy, it will usually provide some coverage claims. Receipt of payment statements suitable for mental health treatmentinsurance submission are issued at the end of each month and list all the sessions for that month. I will fill out forms and provide you with whatever assistance I can in helping you receive benefits to which you are entitled; howeverHowever, you (not your insurance company) are responsible for full payment of my our fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I we will provide you with whatever information I we can based on my our experience and will be happy to help you in understanding the information you receive from your insurance company. If it financial limitations are going to limit your participation in therapy, you should discuss this with your therapist prior to starting therapy or as soon as such information is necessary to clarify benefit, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complexavailable. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans our belief that patients with significant financial limitations are often limited better served by using in-network providers rather than limiting their access to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the caseyou choose to submit your receipts to your insurance company, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most your contract with your health insurance companies require company requires that we provide it with information relevant to the services that we provide to you. An insurance company or other third-party payor regulated under New Jersey law may request that the patient authorize the psychologist to disclose certain confidential information to the third-party payor in order to obtain benefits, only if the disclosure is pursuant to a valid authorization and the information is limited to: Administrative Information, Diagnostic Information, Patient’s Status, Reason for Continuing Services, and Prognosis. If the third-party payor has reasonable cause to believe that the psychological treatment in question may be neither usual, customary nor reasonable, the third-party payor may request, in writing, and compensate reasonably for, an independent review of such treatment by an independent review committee. You should be aware that if your health benefits are provided by a self insured employee benefit plan or other arrangement regulated by the federal ERISA statute, such plan will have considerably more access to information in your Clinical Record. They will not have access to your Psychotherapy Notes. If you to authorize me to provide them with a clinical diagnosis. Sometimes I am required to relate additional clinical information such as treatment plans or summaries, or copies have any question about the nature of your entire record (in rare cases)health benefits, you should contact the group that provides the benefits for you. This information will become part of the insurance company’s company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I we have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I We will provide you with a copy of any report I we submit, if you request it. Once we have all the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatment. It is important to remember that you always have the right to pay for my services yourself to avoid these problems that compromise your full confidentiality.
Appears in 1 contract
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree agreed to otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay Payments for servicesservices can be made by cash, you are ultimately responsible to pay for servicescheck and credit card. Payment that We add a 3.5% surcharge on all credit card payments. This surcharge is not made at the time greater than our total cost of accepting credit cards. There is no surcharge for debit card payments. We encourage you to take a session is expected within 30 days. I am happy receipt for all cash transactions in order to work with patients to arrange for payment plans if that becomes necessarybest serve you. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have Vista Psychological & Counseling Centre, LLC, has the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action becomes necessary, court which will require the costs will be included in the claimclinician to disclose otherwise confidential information. In most collection situations, the only information I that the clinician will release regarding a client’s treatment is the client’s his/her name, the nature of the services provided (i.e. individual psychotherapy)provided, dates of service, and the amount due. Initials (of Individual, couple or family) 3 In order for us Vista Psychological & Counseling Centre, LLC, to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I Vista Psychological & Counseling Centre, LLC, will fill out forms and provide you with whatever assistance I we can in helping you receive the benefits to which you are entitled; however. However, you (not your insurance company) are responsible for full payment of my the clinician’s fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and Vista Psychological & Counseling Centre, LLC, will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefitclear confusion, I Vista will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term short‐term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy psychotherapy/counseling after a certain number of sessions. While much can be accomplished in short-short term therapypsychotherapy/counseling, some clients feel that they need more services service after insurance benefits end. (Some managed- care managed‐care plans will not allow me the clinician to provide services to you once your benefits end. If this is the case, I the clinician will do my their best to of find another provider who will help you continue your psychotherapy.) /counseling. You should also be aware that most your contract with your health insurance companies require you company requires that the clinician provide it with information relevant to authorize me the services provided to you. The clinician is required to provide them with a clinical diagnosis. Sometimes I am the clinician is required to relate provide additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases)clinical record. In such situations, the clinician will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company’s company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have the clinician has no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I The clinician will provide you with a copy of any report I they submit, if you request it. By signing this Agreement, you agree that the clinician can provide requested information to your insurance carrier. Once we have Vista Psychological & Counseling Centre, LLC, has all of the information about your insurance coverage, we it will be possible to discuss what we can expect to accomplish be accomplished with the benefits that are available and what will happen if they run out before you feel ready to end your treatmentsessions. It is important to remember that you always have the right to pay for my the clinician’s services yourself to avoid these the potential problems described above. Under changes to HIPAA in 2009, you now have the right to elect not to use insurance when seeing a therapist and then no information will be disclosed to your insurance company. You should be aware, however, that compromise you have to make such an election prior to each therapy session and you must pay for those services at that time. You will be charged allowable fees under such circumstances. Should you elect to not use your full confidentialityinsurance, or the services are not covered by insurance or are out of network with your insurance, you are entitled under the No Surprise Act to receive a good faith estimate. Separate paperwork has been provided pertaining to this 2022 No Surprise Act legislation and is also available on our website ▇▇▇.▇▇▇▇▇▇▇▇.▇▇▇. You also have the option to waive your federal consumer protections when the nature of mental health concerns do not lend themselves to a good faith estimate.
Appears in 1 contract
Sources: Clinician Client Services Agreement
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangementI accept. Payment schedules for other professional services will be agreed to when they at the time these services are requested. If your insurer determines Insurance plans typically assign a co-pay amount to be paid by the insured, and may also require that they will not the insured pay for servicesany sales tax (in Hawaii, you are ultimately responsible General Excise Tax). In circumstances of unusual financial hardship, I may be willing to pay for services. Payment that is not made at the time of negotiate a session is expected within 30 daysfee adjustment or installment payment plan. I am happy accept some credit cards, but these financial considerations are on a case by case basis and solely up to work with patients to arrange for payment plans if that becomes necessarymy discretion. If your account has not been paid for is more than 60 30 days in arrears and suitable arrangements for payment have not been agreed uponto, I have the option of using a legal means to secure the payment. This may involve hiring a , including collection agency agencies or going through small claims court. If such legal action becomes necessary, the costs which will be included in the claimrequire me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a client’s treatment is the client’s name, the nature of the services provided (i.e. individual psychotherapy)provided, and the amount due. Initials (of IndividualIf such legal action is necessary, couple or family) 3 its costs will be included in the claim. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have are available to pay for your treatment. If you have a health insurance benefits policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive facilitating your receipt of the benefits to which you are entitled; however, you (including filling out forms as appropriate. However, you, and not your insurance company) , ultimately are responsible for full payment of my feesthe fee. It Therefore, it is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions, you should direct these questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If The rising cost of healthcare has resulted in an increasing level of complexity about insurance benefits, which sometimes makes it is necessary to clarify benefit, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health CareCare Plans” plans such as HMOs and PPOs often require pre- advance authorization before they will provide reimbursement for mental health services. These plans are often limited to oriented towards a short-term treatment approaches approach designed to work out resolve specific problems that interfere are interfering with a person’s usual level of functioning. It may be necessary to seek additional approval for more therapy after a certain number of sessions. While much In my experience, while quite a lot can be accomplished in short-short term therapy, some many clients feel they need that more services are necessary after insurance benefits endexpire. (Some managed- managed-care plans will may not allow me to provide pay for services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) . You should also be aware that most some insurance companies agreements may require you to authorize me to provide them with a clinical diagnosis. Sometimes I am required to relate diagnostic impression, and sometimes additional clinical information such as a treatment plans plan or summariessummary, or copies of your entire record (in rare cases)treatment notes. This information will become part of the insurance company’s files and company files, and, in all probability, some or all of it will probably be stored in a computerdigitized. Though all All insurance companies claim to keep such information confidential, but once in their possession, I have no control over what they do with it once it is this information. For example, in their hands. In some cases, they may share the information with a national medical databankinformation data bank. I will provide you with a copy of any report I submit, if you request it. Once we have all By signing this Agreement, you agree that I can provide requested information to your insurance carrier. I am often not immediately available by telephone or e-mail. My communications are limited to my availability during normal business hours, defined as Monday through Friday, 8:00 a.m. to 5:00 p.m., excluding holidays. If you leave me a voicemail or send me an e-mail, I will make every effort to return your call or e-mail as soon as I become available during business hours. I do not usually return cellular text message communications unless they are limited to scheduling. Please understand that contact with me during business hours is dependent upon my availability. If there is an emergency requiring immediate clinical care, you may contact your physician, the 24-hour crisis line (▇-▇▇▇-▇▇▇-▇▇▇▇), or dial 9-1-1 and ask for help. Both law and the standards of my profession require that I keep appropriate treatment records, which include what is called Protected Health Information (PHI). This includes, for example, information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance coveragecarrier. Except in unusual circumstances that involve danger to yourself and/or others, we or if your clinical records makes reference to another person (other than another health care provider) and I believe that access is reasonably likely to cause substantial harm to such other person, or where information has been supplied to me by others confidentially, you may examine and/or receive a copy of your clinical record if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. I will charge a preparation fee and for certain other expenses related to the request of your file. It will be your responsibility to arrange for a third party, such as a Court reporter or medical copy service, to obtain the records, create a copy, and return the file to me. Your responsibility also includes all financial obligations concerning the third party fees. If I deny your request for access to your records, you have a right of review (except for information provided to me confidentially by others), which I will discuss with you upon your request. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides you with several rights with regard to your clinical record and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what we can expect information from your clinical record is disclosed to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatment. It is important to remember others; requesting an accounting of most disclosures of protected health information that you always have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to pay a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. Clients under 18 years of age and their parents should be aware that the law allows parents to examine their child’s treatment records unless we have agreed otherwise, or unless I decide that such access is likely to injure the child. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from parents that they give up their access to their child’s records. If they agree, then during treatment I will provide parents only with general information about the progress of the child’s treatment and attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communications will require the child’s assent, unless I feel that the child is in danger or is a danger to someone else. In that case, I will notify the parents of my concerns. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections the child may have. Hawaii State Law has determined that if parents are involved in a custody dispute, the Court shall appoint a Guardian Ad Litem to secure the release of records for my services yourself the child(ren) involved. In general, the confidentiality of all communications between a client and a psychologist is protected by law. In most situations, I can only release information about your treatment to avoid these problems others if you sign a written authorization form that compromise your full confidentiality.meets certain legal requirement imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:
Appears in 1 contract
Sources: Client Services Agreement
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay for services, you are ultimately responsible to pay for services. Payment that is not made at the time of a session is expected within 30 days. I am happy to work with patients to arrange for payment plans if that becomes necessary. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I we have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims courtcourt which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action becomes is necessary, the costs will be included in the claim. In most collection situations, the only information I release regarding treatment is the client’s name, the nature ▇▇▇▇▇ & Associates Therapists accept these insurances (but please call your insurance carrier to verify your plan with each therapist): AETNA American Behavioral Blue Cross Blue Shield of the services provided (i.e. individual psychotherapy), and the amount due. Initials (Alabama Behavioral Health Systems Cigna Cigna HealthSpring Medicare Multi Plan/PHCS OPTUM/UBH/UHC Tricare Out of Individual, couple or family) 3 In order for us to State BCBS Plans Beacon So that we can set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I We will fill out forms file your insurance claim and provide you with whatever assistance I we can in helping you receive the benefits to which you are entitled; : however, you (not your insurance company) are responsible for full payment of my our fees. It is important that As stated earlier, you find out exactly what mental health services must call your insurance policy covers. You should carefully read company to verify coverage and obtain pre-authorization (if required) before the section in your insurance coverage booklet that describes mental health services. If first visit, or you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy asked to help you in understanding pay full fee for the information you receive from your insurance company. If it is necessary to clarify benefit, I will be willing to call the company on your behalf. first visit Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients patients feel that they need more services after insurance benefits end. (Some managed- care plans At this point, the client will not allow me be required to provide services to you once your benefits endpay full fee out of pocket, unless the MHP and client discuss a reduced fee in advance of the first non-covered session. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most your contract with your health insurance companies require you company requires that we provide it with information relevant to authorize me the services that we provide to you. We are required to provide them with a clinical diagnosis. Sometimes I am we are required to relate provide additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases)Clinical Record. In such situations, we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company’s company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I we have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I We will provide you with a copy of any report I submit, we submit if you request it. By signing this Agreement, and the accompanying Authorization, you agree that we can provide requested information to your carrier. Once we have all the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatmentsessions. It is important to remember that you always have the right to pay for my our services yourself to avoid these the problems that compromise your full confidentiality.described above. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS. YOUR SIGNATURE ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE Printed name of Patient Signature of Patient (Parent or legal guardian, if child is under age 14) Date signed Revised 4/21 Pitts&Associates I. • • − − − • •
Appears in 1 contract
Sources: Therapist Client Services Agreement
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay for services[In circumstances of unusual financial hardship, you are ultimately responsible I may be willing to pay for services. Payment that is not made at the time of negotiate a session is expected within 30 days. I am happy to work with patients to arrange for fee adjustment or payment plans if that becomes necessary. installment plan.] If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action becomes necessary, the costs court which will be included in the claimrequire me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a client’s treatment is the client’s his/her name, the nature of the services provided (i.e. individual psychotherapy)provided, and the amount due. Initials (of Individual[If such legal action is necessary, couple or family) 3 its costs will be included in the claim.] In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefitclear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits end. ([Some managed- managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) ] You should also be aware that most your contract with your health insurance companies require you company requires that I provide it with information relevant to authorize me the services that I provide to you. I am required to provide them with a clinical diagnosis. Sometimes I am required to relate provide additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases)clinical record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company’s company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatmentsessions. It is important to remember that you always have the right to pay for my services yourself to avoid these the problems that compromise your full confidentialitydescribed above [unless prohibited by contract].
Appears in 1 contract
Billing and Payments. You will be expected to pay for each session at no later than the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be due by the end of the month after they occur, unless another arrangement is agreed to when they the services are requested. If your insurer determines that they will not pay for services, you are ultimately responsible to pay for services. Payment that is not made at the time of a session is expected within 30 days. I am happy to work with patients to arrange for payment plans if that becomes necessary. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action becomes necessary, the costs will be included in the claim. In most collection situations, the only information I release regarding a client’s treatment is the client’s his or her name, billing address, the dates and nature of the services provided (i.e. individual psychotherapy)provided, and the amount due. Initials (of IndividualSouth County Psychological, couple or family) 3 In order for us to set realistic goals and prioritiesInc. accepts some insurances. New contracts are continually being sought, it so ask if your plan is important to evaluate what resources accepted. You will be notified if South County Psychological, Inc. is placed on an insurance panel while you have available to pay for your are in treatment. If you have a However, some health insurance policy, it will usually provide some coverage for mental health treatmentpolicies do allow you to see a professional who is not in their pre- approved network; this is often referred to as seeing an “out of network provider”. I will fill out forms and provide you with whatever assistance I can in helping a receipt called a “Super Bill”, which some insurance policies will accept to reimburse you receive benefits to which you are entitled; howeverfor some or all of your therapy expenses. However, you (not your insurance company) are responsible for full payment of my fees. It If your insurance will allow you to see an Out of Network Provider, it is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coveragecoverage or if they will reimburse you for therapy expenses with a Super Bill, call your plan administrator. Of courseIf you are eligible for this arrangement and your insurance company requires more information about your treatment, we will discuss the information they want. If you agree to have me provide that information to the insurance company, I will provide need you to sign a Release of Information to allow me to share your information with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefit, I will be willing to call the company on your behalf. Due to the rising risking costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” Many managed health care plans such as HMOs and PPOs often require pre- authorization before they the service is provided in order for the insurance company to provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much a lot can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits end. (Some managed- managed care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best offer you referrals to find facilitate your finding another provider who will help with whom you may choose to continue your psychotherapy.) . You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I am required have to relate provide additional clinical information such as treatment plans or summaries, or copies of your the entire record (in rare cases). This With your authorization, I will provide treatment plans and summaries, but I will not provide copies of your entire treatment record to an insurance company, as I feel it grossly violates you right to confidential treatment, as all of that information will become becomes a part of the insurance company’s company files and will probably may be stored in on a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, submit if you request it. Once we If your insurance policy will accept a Super Bill and you wish to use your insurance benefits, once you have all the information about your insurance coverage, we will can discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatmentour sessions. It is important to remember that you always have the right to pay for my services yourself to avoid these the problems that compromise described above. I am often not immediately available by telephone. During many days and Saturdays, I am often with a client and will not answer the phone when I am in session. When I am unavailable, you are free to leave a message on my voice mail. I will make every effort to return your full confidentialitycalls within 24 hours, with the exception of Sundays, holidays, and when I am on vacation. If I will be unavailable for an extended period of time, I will provide you with information or leave instructions on my voice mail for you to reach a trusted colleague for assistance if necessary. If you have a life threatening emergency, you must call 911 or go to your nearest emergency room and ask for the psychologist/psychiatrist on call to obtain immediate assistance. My voice mail does NOT provide immediate assistance during a life threatening emergency.
Appears in 1 contract
Sources: Outpatient Services Contract
Billing and Payments. You will be expected to pay for each session services at the time it is heldbeginning of each session, unless we agree otherwise you are an EAP referral or unless you have your insurance coverage that carrier requires another arrangement. Payment schedules for other professional services will Please discuss this with me before your first session. • In circumstances of temporary unusual financial hardship, I may be agreed willing to when they are requested. If your insurer determines that they will not pay for services, you are ultimately responsible to pay for services. Payment that is not made at the time of negotiate a session is expected within 30 daysshort-term fee adjustment. I am happy to work with patients to arrange can also give you referrals for payment plans if practitioners or agencies that becomes necessaryprovide sliding scale payments. • If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action becomes necessary, the costs court which will be included in the claimrequire me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a Client’s treatment is the client’s his/her name, the nature of the services provided (i.e. individual psychotherapy)provided, and the amount due. Initials (of IndividualIf such legal action is necessary, couple or family) 3 related costs will be included in the claim. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. If I am an out-of-network provider, your plan may include deductible and higher co-pay than if I am an in-network provider. I will fill out forms bill your insurance company, unless we agree otherwise, and provide you with whatever assistance I can in helping you receive benefits to which you are entitled; howeveran invoice of our sessions, you (however you, not your insurance company) , are responsible for full payment of my fees. It You may pay by cash, check, or credit card. However, if your check bounces, you will be responsible for paying the fee that my bank charges me as well as the full amount. Thereafter I will no longer accept checks from you and you must pay in cash or by credit card. I will contact your insurance company or EAP provider to verify your mental health benefits. Since mental health benefits may differ from medical benefits, it is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefit, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out on specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most your contract with your health insurance companies company might require you that I provide information relevant to authorize me the services that I provide to you. I am required to provide them with a clinical diagnosis. Sometimes I am required to relate provide additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases)Clinical Record, except for therapy Notes. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company’s company files and will probably be stored in a computertheir computer system. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverageauthorized services, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatmentsessions. It is important to remember that you always have the right to pay for my services yourself to avoid these the problems that compromise described above, unless prohibited by your full confidentialitycontract. You may also elect to pay my fees if you decide to continue services even though denied by your insurance company or EAP provider, unless prohibited by your contract.
Appears in 1 contract
Sources: Counselor Client Services Agreement
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangementotherwise. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay for services, you Returned checks are ultimately responsible subject to pay for services. Payment that is not made at the time of a session is expected within 30 days. I am happy to work with patients to arrange for payment plans if that becomes necessary$35 fee. If your account has not been paid for more than 60 days 90 days, and suitable arrangements for payment have not been agreed upon, I we have the option of suspending or discontinuing treatment, and/or using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court, which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a patient’s treatment is his/her name, dates, the nature of services provided, and the amount due. If such legal action becomes is necessary, the its costs will be included in the claim. In most collection situations, the only information I release regarding treatment is the client’s name, the nature of the services provided (i.e. individual psychotherapy), and the amount due. Initials (of Individual, couple or family) 3 In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I Warner & Associates, LLC does not participate with any insurance companies. We will fill out forms and provide you with whatever assistance I can in helping you receive benefits an invoice to which you are entitled; however, you (not submit to your insurance company) are responsible company or flexible spending account for full payment of my feesreimbursement, according to your individual health insurance plan benefits. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I we will provide you with whatever information I we can based on my experience our experience, and will be happy to attempt to help you in understanding the information you receive from required by your insurance companycompany for reimbursement. If it is necessary to clarify benefitYOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA FORM DESCRIBED ABOVE. Client Name Client Signature (if 18 or over) Parent/Guardian Name (if applicable) Date Parent/Guardian Signature (if applicable) Warner & Associates, LLC Staff Name Date Warner & Associates, LLC Staff Signature I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems acknowledge that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I am required to relate additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases). This information will become part of the insurance company’s files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some casesreceived, they may share have read, and understand the information with a national medical databank“General Information and Psychological Services Agreement.” I have had my questions answered adequately at this time. I will provide you with a copy of any report understand that I submit, if you request it. Once we have all the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatment. It is important to remember that you always have the right to ask questions throughout the course of my assessment and/or treatment and may request an outside consultation. I also understand that the mental health provider may offer additional information about specific treatment issues and treatment methods on an as- needed basis during the course of my treatment or evaluation, and that I have the right to consent to or refuse such treatment. I understand that I can expect regular review of treatment to determine whether treatment goals are being met. I agree to be actively involved in the treatment, and in the review process. No promises have been made as to the results of this treatment or evaluation, or of any procedures utilized within it. I further understand that I may stop my treatment or evaluation at any time, but agree to discuss this decision first with my mental health provider. My only obligation, should I decide to stop treatment, is to pay for the services I have already received, and to attend one final session to discuss my services yourself reasons and to avoid terminate. I have been informed that I must give 24 hours notice to cancel an appointment, and that I will be charged $80.00 if I do not cancel or show up for a scheduled session. I am aware that I must authorize the mental health provider in writing to release information about my treatment, but that confidentiality can be broken under certain circumstances of danger to myself or others. I understand that once I release information to insurance companies or any other third party, there is no guarantee that it will remain confidential. My signature signifies my understanding and agreement with these problems issues, and with the additional information conveyed in this statement. Client Name Date Client Signature (if 18 or over) Patient/Guardian Name (if applicable) Date Patient/Guardian Signature (if applicable) Warner & Associates, LLC Staff Name Date Warner & Associates, LLC Signature Client Name: M / F Age: Date of Birth: / / City/State: Zip: I certify that compromise your full confidentiality.the information provided above is complete and accurate. I agree to notify Warner & Associates, LLC if there are any changes in the above information. Client Name: Client Signature: Date: Notice of Policies and Practices to Protect the Privacy of Patient Health Information
Appears in 1 contract
Sources: General Information and Psychological Services Agreement
Billing and Payments. You will be expected to pay in full for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangementof service. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they Methods of accepted payment are check, cash, and credit cards (i.e., MasterCard, Visa, and Discover). There is a $10.00 convenience fee for processing credit cards. There will not pay be a $35.00 charge for services, you are ultimately responsible to pay for services. Payment that is not made at the time of a session is expected within 30 days. I am happy to work with patients to arrange for payment plans if that becomes necessaryreturned checks. If your account has not been paid for more than 60 days and arrangements for payment payments have not been agreed upon, I have the option of using a legal means to secure the payment. This may involve hiring hire a collection agency or going go through small claims court. If such legal action becomes necessary, the costs which will be included in the claimrequire me to disclose confidential information. In most collection situations, the only information I release regarding a patient’s treatment is the client’s his/her name, the nature of the services provided (i.e. individual psychotherapy)provided, and the amount due. Initials If legal action is necessary, its costs will be included in the claim. Additional measures may be necessary if your unpaid balance becomes excessive. Because there are times when patients may not pay at the time of sessions (of Individuale.g. forgotten checkbooks, couple minors coming to therapy without parents, missed appointments, etc.), you may be asked to provide a credit card number to keep on file. This credit card information may be used to collect payment or family) 3 In order for us to set realistic goals outstanding balances, including appointments missed or rescheduled without the required notice, unless other arrangements are made. Credit cards transactions are processed through Inuit GoPayment, which encrypts its data and prioritiescomplies with Payment Card Industry Data Security Standard. No information about the services provided, it other than cost, is important to evaluate what resources you have available to pay for your treatmentshared with the company. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefit, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health servicesservices and it may be necessary to seek approval for more therapy after a certain number of sessions. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual normal level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While Although much can be accomplished in short-term therapy, some clients feel patients decide they need more services after insurance benefits end. (Some managed- care plans will not allow Before beginning treatment, it is very important that you ascertain which mental health services your insurance policy covers. If you have questions about coverage, call your insurance plan administrator. Sometimes your insurer may require me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I am required to relate additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases)Clinical Record. This information will become part of the insurance company’s files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidentialIf so, I have will make every effort to release only the minimum information about you that is necessary for the purpose requested. Maryland law prevents insurers from making unreasonable demands for information, but there are no control over specific guidelines defining what they do with it once it is in their hands. In some cases, they may share the information with a national medical databankunreasonable. I will provide you with a copy of any report I submit, if you request it. Once we have all the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatment. It is important to remember that you always have the right to pay for my services yourself to avoid these problems that compromise your full confidentiality.
Appears in 1 contract
Sources: Patient Services Agreement
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangementotherwise. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they (In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan). You will be responsible for all charges denied and/or not pay covered by insurance. Please make all checks payable to Sea Change, LLC and/or ▇▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇, MA, LPC. There is a $25.00 fee for services, you are ultimately responsible to pay for services. Payment that is not made at the time of a session is expected within 30 days. I am happy to work with patients to arrange for payment plans if that becomes necessaryany returned checks. If your account has not been paid for more longer than 60 days days, and arrangements for payment have not been agreed upon, I have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. (If such legal action becomes is necessary, the its costs will be included in the claim). In most collection situations, the only information I release regarding a patient’s treatment is the client’s his/her name, the nature of the services provided (i.e. individual psychotherapy)provided, and the amount due. Initials (of Individual, couple or family) 3 In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can can, based on my experience experience, and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefitclear confusion, I will would be willing to call the insurance company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans plans, such as as, HMOs and PPOs PPOs, often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches approaches, designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I am required to relate have provided additional clinical information information, such as as, treatment plans or summaries, or copies of your the entire record (in rare cases). This information will become part of the insurance company’s company files and will probably be stored in a computer. Though Although all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their handspossession. In some cases, they may share the information with a national medical databankNational Medical Information Databank. I will provide you with a copy of any report that I submit, if you request it. Once we have all the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatmentour sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above (unless prohibited by contract). I am often immediately available by telephone. While I am in my office and with a client, I will not answer the phone. When I am unavailable, my telephone is answered by a voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it. If you are difficult to reach, please inform me of some times when you will be available. Any telephone conversations lasting longer than 5 minutes will result in a fee of $1.00 per minute. In emergencies, if you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the counselor/therapist/psychiatrist on-call. In addition, you may also call the help line at (602) 254-HELP (4357). If I will be unavailable for an extended time (ie. vacation, conferences, etc.), I will provide you with the name of a colleague to contact should it become necessary. As I am sure you are aware, I am required to keep records of our work together. As these problems records contain information that compromise can be misunderstood by someone who is not a mental health professional, it is my general policy that patients may not review them; however, I will provide, at your full confidentialityrequest, a treatment summary, unless I believe that to do so would be emotionally damaging. If that is the case, I will be happy to send the summary to another mental health professional that is working with you.
Appears in 1 contract
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise your doctor agrees other- wise or unless you have insurance coverage that coverage, which requires another arrangement. If you have insur- ance, your copay is due at the time of your session. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay for servicesIn circumstances of unusual financial hardship, you are ultimately responsible we may be willing to pay for services. Payment that is not made at the time of negotiate a session is expected within 30 days. I am happy to work with patients to arrange for fee adjustment or payment plans if that becomes necessaryinstallment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I we have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action becomes is necessary, the its costs will be included in the claim. In most collection situations, the only information I we release regarding re- ▇▇▇▇▇▇▇ a patient’s treatment is the client’s his/her name, the nature of the services provided (i.e. individual psychotherapy)provided, and the amount due. Initials (of Individual, couple or family) 3 In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I Your doctor will fill out forms and provide you with whatever assistance I they can in helping you receive the benefits to which you are entitled; howeverhow- ever, you (not your insurance company) are responsible for full payment of my your doctor’s fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I course your doc- tor will provide you with whatever information I they can based on my their experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary neces- sary to clarify benefitclear confusion, I your doctor will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I am required to relate additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases). This information will become part of the insurance company’s files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical databank. I will provide you with a copy of any report I submit, if you request it. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatmentsessions. It is important to remember that you always have the right to pay for my your doctor’s services yourself to avoid these the problems described above [unless prohibited by contract]. Your doctor may not be immediately available by telephone. Usual business hours are weekdays be- tween 8 AM and 5 PM. Due to the nature of their work, doctors will not answer the phone when with a patient. When unavailable, your doctor’s telephone is answered by confidential voice mail that compromise is monitored frequently. Your doctor will make every effort to return your full confidentialitycall on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform your doctor of some times when you will be available. Your doctor cannot respond to emergencies on the phone. If you are unable to reach your doctor and feel that you can’t wait for your doctor to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call or go to the nearest emergency room. You may contact the 24-hour Crisis Hot- line at (▇▇▇) ▇▇▇-▇▇▇▇. If your doctor will be unavailable for an extended time, they will provide you with the name of a colleague to contact, if necessary.
Appears in 1 contract
Sources: Informed Consent & Therapy Agreement
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangementotherwise. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay for services(In circumstances of unusual financial hardship, you are ultimately responsible I may be willing to pay for servicesnegotiate a fee adjustment or payment installment plan. Payment that is not made at the time of a session is expected within 30 days. I am happy to work Please discuss this with patients to arrange for payment plans me if that becomes necessarythis need arises). If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. (If such legal action becomes is necessary, the its costs will be included in the claim. .) In most collection situations, the only information I release regarding a patient’s treatment is the client’s his/her name, the nature of the services provided (i.e. individual psychotherapy), and the amount due. Initials (of Individual, couple or family) 3 In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your I am not on any insurance coverage booklet that describes mental health services. If panels, therefore, you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive responsible for collecting from your insurance company. If it is necessary to clarify benefit, I will be willing to call plan the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is availablebenefits that are reimbursable through your plan. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I am required have to relate provide additional clinical information such as treatment plans or summaries, or copies of your the entire record (in rare cases). This information will become part of the insurance company’s company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. Once we have all the I will request you provide me, in writing, a release that I provide this information about to your insurance coveragecompany. I am often not immediately available by telephone, we as I am in sessions. While I am usually in my office between 9 AM and 6 PM, Monday-Thursday, I probably will discuss what we not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by an answering voice mail, or by my secretary whom you can expect reach by dialing “0” (that I monitor frequently, or who knows where to accomplish reach me). I will make every effort to return your call within 48 hours you make it, with the benefits that exception of Fridays, weekends and holidays. If your are available also not immediately available, please inform me of some times when you will be available. (in emergencies and what will happen if they run out before urgent matters, my urgent pager number of ▇▇▇-▇▇▇-▇▇▇▇, ext 208 which has directions on the options in the event of a mental health emergency.). If you are unable to reach me and feel ready to end your treatment. It is important to remember that you always have can’t wait for me to return your call, contact your family physician or the right nearest emergency room and ask for the psychologist (psychiatrist) on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to pay for my services yourself to avoid these problems that compromise your full confidentialitycontact, if necessary. On the AAFPC website; ▇▇▇▇▇.▇▇▇.
Appears in 1 contract
Sources: Psychological Services Contract
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that coverage, which requires another arrangement. Payment schedules Please see our fee schedule, below. Fee Schedule: Initial appointment : $210 Individual, couples or family session $180.00 Telephone sessions (per 15 minute increments) $60.00 Correspondence (per 15 minute increments) $60.00 Psychological evaluations and testing (per hour) $200.00 Forensic work and court appearances (per hour) $300.00 Returned Check Fee $25.00 It is often necessary when seeing children in psychotherapy for other professional services the clinician to spend time outside of the session working on the case. Insurance typically only covers face to face therapy and therefore such outside of the session time is billed directly to parents. I will notify you when these circumstances arise. Additional fees will be agreed to when they are requestedbilled for the following types of situations: communicating with your child's guidance counseler or teacher, reading previous evaluations or reports, revising 504 plans or IEPs, attending school meetings, scoring assessment measures or other diagnostic evaluations. If your insurer determines that they will not pay Fee is $6 0 for services, you are ultimately responsible to pay for services. Payment that is not made at the time 15 minute increments of a session is expected within 30 days. I am happy to work with patients to arrange for payment plans if that becomes necessarytime. If your account has not been paid for is more than 60 days in arrears and suitable arrangements for payment have not been agreed uponto, I have the option of using a legal means to secure the payment. This may involve hiring a , including collection agency agencies or going through small claims court. If such legal action becomes is necessary, the costs of bringing that proceeding will be included in the claim. In most collection situationscases, the only information information, which I would release regarding treatment is to a court or collection agency, would be the client’s name, the nature of the services provided (i.e. individual psychotherapy), and the amount due. Initials (of Individual, couple or family) 3 In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have are available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive facilitating your receipt of the benefits to which you are entitled; however, you (including filling out forms as appropriate. However, you, and not your insurance company) , are responsible for full payment of my feesthe fee. It Therefore, it is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coveragequestions, you should call your plan administratoradministrator and inquire. Of course, I will provide you with whatever information I can based on my experience and will be happy to help try to assist you in understanding deciphering the information you receive from your insurance companycarrier. If it is necessary to clarify benefitresolve confusion, I will be am willing to call the company carrier on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I am required to relate additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases). This information will become part of the insurance company’s files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical databank. I will provide you with a copy of any report I submit, if you request it. Once we have all the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatment. It is important to remember that you always have the right to pay for my services yourself to avoid these problems that compromise your full confidentiality.
Appears in 1 contract
Sources: Outpatient Services Agreement
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay for servicesIn circumstances of unusual financial hardship, you are ultimately responsible to pay for services. Payment that is not made at the time of a session is expected within 30 days. I am happy to work may discuss payment arrangements with patients to arrange for payment plans if that becomes necessaryyour clinician. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I we have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims courtcourt which will require me to disclose otherwise confidential information. In most collection situations, the only information RSA will release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action becomes is necessary, the its costs will be included in the claim. In most collection situations, the only information I release regarding treatment is the client’s name, the nature of the services provided (i.e. individual psychotherapy), and the amount due. Initials (of Individual, couple or family) 3 In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I RSA will fill out forms and provide you with whatever assistance I we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my our fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I we will provide you with whatever information I we can based on my our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefit, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients patients feel that they need more services after insurance benefits end. (Some managed- managed-care plans will not allow me us to provide services to you once your benefits end. If this is the case, I we will do my our best to find another provider who will help you continue your psychotherapy.) . You should also be aware that most your contract with your health insurance companies require you company requires that RSA provide it with information relevant to authorize me the services provided to you. Clinicians are required to provide them with a clinical diagnosis. Sometimes I am we are required to relate provide additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases)Clinical Record. In such situations, RSA will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company’s company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have RSA has no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I Your clinician will provide you with a copy of any report I submithe or she submits, if you request it. By signing this Agreement, you agree that RSA and your clinician can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatmentsessions. It is important to remember that you always have the right to pay for my services yourself to avoid these the problems that compromise your full confidentialitydescribed above, unless prohibited by contract.
Appears in 1 contract
Sources: Provider Patient Services Agreement
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangementotherwise. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay for servicesIn circumstances of unusual financial hardship, you are ultimately responsible I may be willing to pay for services. Payment that is not made at the time of negotiate a session is expected within 30 days. I am happy to work with patients to arrange for payment plans if that becomes necessaryinstallment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action becomes necessary, the costs court which will be included in the claimrequire me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is the client’s his/her name, the nature of the services provided (i.e. individual psychotherapy)provided, and the amount due. Initials (of IndividualIf such legal action is necessary, couple or family) 3 its costs will be included in the claim. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefitclear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients patients feel that they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most your contract with your health insurance companies require you company requires that I provide it with information relevant to authorize me the services that I provide to you. I am required to provide them with a clinical diagnosis. Sometimes I am required to relate provide additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases)Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company’s company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatmentsessions. It is important to remember that you always have the right to pay for my services yourself to avoid these the problems that compromise your full confidentialitydescribed above [unless prohibited by contract].
Appears in 1 contract
Sources: Counselor Client Service Agreement
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree agreed to otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay for services, you are ultimately responsible to pay for services. Payment that is not made at the time of a session is expected within 30 days. I am happy to work with patients to arrange for payment plans if that becomes necessary. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have Vista Psychological & Counseling Centre, LLC, has the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action becomes necessary, court which will require the costs will be included in the claimclinician to disclose otherwise confidential information. In most collection situations, the only information I that the clinician will release regarding a client’s treatment is the client’s his/her name, the nature of the services provided (i.e. individual psychotherapy)provided, dates of service, and the amount due. Initials (of Individual, couple or family) 3 In order for us Vista Psychological & Counseling Centre, LLC, to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I Vista Psychological & Counseling Centre, LLC, will fill out forms and provide you with whatever assistance I we can in helping you receive the benefits to which you are entitled; however. However, you (not your insurance company) are responsible for full payment of my the clinician’s fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and Vista Psychological & Counseling Centre, LLC, will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefitclear confusion, I Vista will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term short‐term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy psychotherapy/counseling after a certain number of sessions. While much can be accomplished in short-short term therapypsychotherapy/counseling, some clients feel that they need more services service after insurance benefits end. (Some managed- care managed‐care plans will not allow me the clinician to provide services to you once your benefits end. If this is the case, I the clinician will do my their best to of find another provider who will help you continue your psychotherapy.) /counseling. You should also be aware that most your contract with your health insurance companies require you company requires that the clinician provide it with information relevant to authorize me the services provided to you. The clinician is required to provide them with a clinical diagnosis. Sometimes I am the clinician is required to relate provide additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases)clinical record. In such situations, the clinician will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company’s company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have the clinician has no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I The clinician will provide you with a copy of any report I they submit, if you request it. By signing this Agreement, you agree that the clinician can provide requested information to your insurance carrier. Once we have Vista Psychological & Counseling Centre, LLC, has all of the information about your insurance coverage, we it will be possible to discuss what we can expect to accomplish be accomplished with the benefits that are available and what will happen if they run out before you feel ready to end your treatmentsessions. It is important to remember that you always have the right to pay for my the clinician’s services yourself to avoid these the potential problems described above. Under changes to HIPAA in 2009, you now have the right to elect not to use insurance when seeing a therapist and then no information will be disclosed to your insurance company. You should be aware, however, that compromise your full confidentialityyou have to make such an election prior to each therapy session and you must pay for those services at that time. You will be charged allowable fees under such circumstances.
Appears in 1 contract
Sources: Clinician Client Services Agreement
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree agreed to otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay Payments for servicesservices can be made by cash, check and credit card. We encourage you are ultimately responsible to pay take a receipt for services. Payment that is not made at the time of a session is expected within 30 days. I am happy all cash transactions in order to work with patients to arrange for payment plans if that becomes necessarybest serve you. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have Vista Psychological & Counseling Centre, LLC, has the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action becomes necessary, court which will require the costs will be included in the claimclinician to disclose otherwise confidential information. In most collection situations, the only information I that the clinician will release regarding a client’s treatment is the client’s his/her name, the nature of the services provided (i.e. individual psychotherapy)provided, dates of service, and the amount due. Initials (of Individual, couple or family) 3 In order for us Vista Psychological & Counseling Centre, LLC, to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I Vista Psychological & Counseling Centre, LLC, will fill out forms and provide you with whatever assistance I we can in helping you receive the benefits to which you are entitled; however. However, you (not your insurance company) are responsible for full payment of my the clinician’s fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and Vista Psychological & Counseling Centre, LLC, will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefitclear confusion, I Vista will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term short‐term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy psychotherapy/counseling after a certain number of sessions. While much can be accomplished in short-short term therapypsychotherapy/counseling, some clients feel that they need more services service after insurance benefits end. (Some managed- care managed‐care plans will not allow me the clinician to provide services to you once your benefits end. If this is the case, I the clinician will do my their best to of find another provider who will help you continue your psychotherapy.) /counseling. You should also be aware that most your contract with your health insurance companies require you company requires that the clinician provide it with information relevant to authorize me the services provided to you. The clinician is required to provide them with a clinical diagnosis. Sometimes I am the clinician is required to relate provide additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases)clinical record. In such situations, the clinician will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company’s company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have the clinician has no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I The clinician will provide you with a copy of any report I they submit, if you request it. By signing this Agreement, you agree that the clinician can provide requested information to your insurance carrier. Once we have Vista Psychological & Counseling Centre, LLC, has all of the information about your insurance coverage, we it will be possible to discuss what we can expect to accomplish be accomplished with the benefits that are available and what will happen if they run out before you feel ready to end your treatmentsessions. It is important to remember that you always have the right to pay for my the clinician’s services yourself to avoid these the potential problems described above. Under changes to HIPAA in 2009, you now have the right to elect not to use insurance when seeing a therapist and then no information will be disclosed to your insurance company. You should be aware, however, that compromise your full confidentialityyou have to make such an election prior to each therapy session and you must pay for those services at that time. You will be charged allowable fees under such circumstances.
Appears in 1 contract
Sources: Clinician Client Services Agreement
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that which requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they (In circumstances of unusual financial hardship, I may be willing to discuss negotiating a fee adjustment. This arrangement will not pay for services, you are ultimately responsible be subject to pay for services. Payment that is not made at the time of a session is expected within 30 days. I am happy to work with patients to arrange for payment plans if that becomes necessary. periodic review.) If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. [If such legal action becomes is necessary, the its costs will be included in the claim. .] In most collection situations, the only information I release regarding a patient's treatment is the client’s his/her name, the nature of the services provided (i.e. individual psychotherapy)provided, and the amount due. Initials (of Individual, couple or family) 3 In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive benefits to which you are entitled; , however, you (not your insurance company) are ultimately responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, please call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefit, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “"Managed Health Care” " plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s 's usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much a lot can be accomplished in short-term therapy, some clients patients feel that they need more services after insurance benefits end. ([Some managed- managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) ] You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I am required have to relate provide additional clinical information such as treatment plans or summaries, or copies of your the entire record (in rare cases). This information will become part of the insurance company’s company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatmentavailable. It is important to remember that you always You have the right to pay for my services yourself exclusively, in order to avoid these problems potential concerns about confidentiality with your private health information.. I am often not immediately available by telephone. I will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by a voicemail that compromise I monitor frequently. I will make every effort to return your full confidentialitycall on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me, can’t wait for a return call, and/or believe that you are in an emergency situation, I ask that you please go to your nearest emergency room.
Appears in 1 contract
Sources: Service Agreement
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In order to streamline billing and minimize the possibility of financial matters intruding on the therapeutic relationship, I agree to place a currently valid credit card on file with HCP and authorize HCP to make appropriate charges on that card for services rendered on or shortly after the date of service. If your insurer determines that they I choose a different form of payment, I will not pay for services, you are ultimately responsible present cash or another valid credit card prior to pay for services. Payment that is not made at the time of a session is expected within 30 days. I am happy to work with patients to arrange for payment plans if that becomes necessarymy session. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have your doctor has the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims courtcourt which will require disclosure of otherwise confidential information. In most collection situations, the only information the doctor releases regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action becomes is necessary, the its costs will be included in the claim. In most collection situations, the only information I release regarding treatment is the client’s name, the nature of the services provided (i.e. individual psychotherapy), and the amount due. Initials (of Individual, couple or family) 3 In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I Your doctor will fill out forms and provide you with whatever assistance I s/he can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my your doctor’s fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I your doctor will provide you with whatever information I s/he can based on my his/her experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefitclear confusion, I your doctor will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients patients feel that they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most your contract with your health insurance companies require you company requires that your doctor provide it with information relevant to authorize me the services that s/he provides to you. Your doctor is required to provide them with a clinical diagnosis. Sometimes I am s/he is required to relate provide additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases)Clinical Record. In such situations, s/he will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company’s company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have your doctor has no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I Your doctor will provide you with a copy of any report I submits/he submits, if you request it. By signing this Agreement, you agree that your doctor can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatmentsessions. It is important to remember that you always have the right to pay for my your doctor’s services yourself to avoid these the problems that compromise your full confidentialitydescribed above unless prohibited by contract.
Appears in 1 contract
Billing and Payments. You will be expected to pay Payment for each session services is the patient’s responsibility and due at the time it is held, unless we agree otherwise or of service unless you have insurance coverage that requires another arrangementarrangement (see Insurance Reimbursement below). Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay for services, you are ultimately responsible to pay for services. Payment that is not made at the time of a session is expected within 30 days. I am happy to work with patients to arrange for payment plans if that becomes necessary. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action becomes necessary, the costs court which will be included in the claimrequire me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is the client’s his/her name, the nature of the services provided (i.e. individual psychotherapy)provided, and the amount due. Initials ([If such legal action is necessary, its costs will be included in the claim.] Any balances due in excess of Individual, couple or family) 3 In order for us 90 days are subject to set realistic goals and priorities, it interest being added. It is important the patient’s responsibility to evaluate what resources you have available to pay for verify the details of your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatmentcoverage with your insurance company(ies) and to determine if an authorization is required. I will fill out forms (Note: Other information you may want to obtain from your insurance company might be: deductible amounts, reimbursement amounts, if authorization is required, number of visits allowed per benefit year, what are the dates of the benefit year, if a referral from your primary care physician or a psychiatrist is required, yearly and provide you lifetime maximum reimbursement amounts, etc. When consulting with whatever assistance I can in helping you receive benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is important , advise them that you find out exactly what are requesting out-of-network, mental health services your insurance policy covers. information.) You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefit, I will be willing to call the company on your behalf. Due to the rising costs of health care, Some insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often companies require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients patients feel that they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits endPlease be advised that I am an "out-of-network" provider with insurance companies. If this is the case, I will do provide you with the completed forms for you to file; however, you (not your insurance company) are responsible for full payment of my best fees. It is very important that you find out exactly what mental health services your insurance policy covers. Any balances due in excess of 90 days are subject to find another provider who will help interest being added. Please discuss the details of secondary or supplemental insurance reimbursement with me or the appropriate business associate that handles this for me. It is your responsibility to advise us if you continue your psychotherapy.) have a change of address, phone number(s), insurance coverage, and/or place of employment so that we can update our file for account accuracy. PLEASE BRING YOUR INSURANCE CARD TO YOUR FIRST APPOINTMENT. You should also be aware that most your contract with your health insurance companies require you company requires that I provide it with information relevant to authorize me the services that I provide to you. I am required to provide them with a clinical diagnosis. Sometimes I am required to relate additional provide addi tional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases)Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company’s company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. Once we have all the By signing this Agreement, you agree that I can provide requested information about to your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatmentcarrier. It is important to remember that you always have the right to pay for my services yourself to avoid these the problems that compromise your full confidentialitydescribed above [unless prohibited by contract].
Appears in 1 contract
Billing and Payments. You will be expected to pay for each session at the time it is held, held unless we agree otherwise or unless you have insurance coverage that coverage, which requires another arrangement. Payment schedules for other professional services will be agreed to when they at the time these services are requested. If your insurer determines that they will not pay for servicesIn circumstances of unusual financial hardship, you are ultimately responsible I’m willing to pay for services. Payment that is not made at the time of negotiate a session is expected within 30 days. I am happy to work with patients to arrange for sliding fee adjustment or installment payment plans if that becomes necessaryplan. If your account has not been paid for is more than 60 days in arrears and suitable arrangements for payment have not been agreed uponto, I have the option of using a legal means to secure the payment. This may involve hiring a , including collection agency agencies or going through small claims court. If such legal action becomes is necessary, the costs of bringing that proceeding will be included in the claim. In most collection situationscases, the only information information, which I release regarding release, about a client's treatment is would be the client’s 's name, the nature of the services provided (i.e. individual psychotherapy)provided, and the amount due. Initials (of Individual, couple or family) 3 In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have are available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive facilitating your receipt of the benefits to which you are entitled; howeverentitled including filling out forms as appropriate. However, you (you, and not your insurance company) , are responsible for full payment of the fee, which we have agreed to, unless this policy is covered in my feescontract, if any, with your insurance company. It Therefore, it is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coveragequestions, you should call your plan administratoradministrator and inquire. Of course, I will provide you with whatever information I can based on my experience and will be happy to help try to assist you in understanding deciphering the information you receive from your insurance companycarrier. If it is necessary to clarify benefitresolve confusion, I will be am willing to call the company carrier on your behalf. Due to The escalation of the rising costs cost of health carecare has resulted in an increasing level of complexity about insurance benefits, insurance benefits have increasingly become more complex. It is which sometimes makes it difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans Care Plans such as HMOs and PPOs often require pre- advance authorization before they will provide reimbursement for mental health services. These plans are often limited to oriented towards a short-term treatment approaches approach designed to work out resolve specific problems that interfere are interfering with a person’s one's usual level of functioning. It may be necessary to seek additional approval for more therapy after a certain number of sessions. While much In my experience, quite a lot can be accomplished in short-short- term therapy, some but many clients feel they need that more services are necessary after insurance benefits endexpire. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most insurance companies agreements require you to authorize me to provide them with a clinical diagnosis. Sometimes I am required to relate , and sometimes additional clinical information such as a treatment plans plan or summariessummary, or copies of your entire record (in rare cases), a copy of the entire record. This information will become part of the insurance company’s files and company files, and, in all probability, some of it will probably be stored in a computercomputerized. Though all All insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with it once it is in their handsit. In some cases, they may share the information with a national medical databank. I will provide you with a copy of any report I submit, if you request itinformation data bank. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they the insurance benefits run out before you feel ready to end your treatmentour sessions. It is important to remember that you always have the right to pay for my services yourself and avoid the complexities, which are described above. Initial for all of the above Many insurance plans do not pay for psychological testing or limit the amount of payment; this is especially true for testing which they consider educational. In these cases, testing is considered a "non-covered benefit". There is much confusion about this because many clients are told by their insurance companies that evaluations are covered-this often means a one-hour, face-to-face clinical interview but not testing. If you plan to avoid these problems that compromise use insurance for testing it is best to let my office manager check on your full confidentialitycoverage for you. We will then let you know, to the best of our knowledge, what portion of the testing your insurance will cover and how much will be your responsibility. Your portion of the testing will be billed at my standard professional fee for "non-covered benefits" plus any co-payment or deductible for your insurance.
Appears in 1 contract
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that which requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay for services, you are ultimately responsible to pay for services. Payment that is not made at the time of a session is expected within 30 days. I am happy to work with patients to arrange for payment plans if that becomes necessary. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action becomes necessary, the costs will be included in the claim. In most collection situations, the only information I release regarding a patient’s treatment is the client’s his/her name, the nature of the services provided (i.e. individual psychotherapy)provided, and the amount due. Initials (of Individual, couple or family) 3 In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, course I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefitclear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much a lot can be accomplished in short-term therapy, some clients patients feel that they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I am required have to relate provide additional clinical information such as treatment plans or summaries, or copies of your the entire record (in rare cases). This information will become part of the insurance company’s company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatmentour sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. I am often not immediately available by telephone. While I am usually in my office between 8 AM and 5 PM, I probably will not answer the phone when I am with a patient. I do check my phone regularly in between sessions when possible. I will make every effort to return your call within 24 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you can’t wait for me to return your call, please go to your nearest emergency room or call 911 or the San Diego County Access Crisis line, (▇▇▇) ▇▇▇-▇▇▇▇. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. As I am sure you are aware, I am required to keep records of the professional services I provide for your treatment, or our work together. Because these problems records contain information that can be misunderstood by someone who is not a mental health professional, it is my general policy that patients may not review them; however, I will provide at your request a treatment summary unless I believe that to do so would be emotionally damaging. If that is the case, I will be happy to send the summary to another mental health professional who is working with you. You should be aware that this will be treated in the same manner as any other professional (clinical) service and you will be billed accordingly. This last section outlines my office policies related to use of Social Media, i.e., how I conduct myself on the Internet as a mental health professional and how you can expect me to respond to various interactions that may occur between us on the Internet. As new technology develops and the Internet changes, there may be times when I need to update these policies. If I do so, I will notify you in writing of any policy changes and make sure you have a copy of the updated policy. I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your full confidentialityconfidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship.
Appears in 1 contract
Sources: Office Policies and Agreement for Psychotherapy Services
Billing and Payments. You will be are expected to pay for each session at the time it is held, held unless we agree otherwise or unless you have your insurance coverage that requires another arrangementarrangement or we have agreed otherwise. Payment schedules for other professional services will be agreed to when they are requested. If For your insurer determines that they will not pay for servicesconvenience I accept cash, you are ultimately responsible to pay for services. Payment that is not made at the time of a session is expected within 30 days. I am happy to work with patients to arrange check and/or credit card (Visa, MasterCard, Discover and American Express) for payment plans if that becomes necessaryof fees. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action becomes is necessary, the its costs will be included in the claim. In most collection situations, the only information I release regarding a patient’s treatment is the client’s his/her name, the nature of the services provided (i.e. individual psychotherapy)provided, and the amount due. Initials (You/Your child should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in one set of Individual, couple or family) 3 In order for us to set realistic goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my feesprofessional records. It is important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefit, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I am required to relate additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases). This information will become part of the insurance company’s files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical databank. I will provide you with a copy of any report I submit, if you request it. Once we have all the includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance coveragecarrier. The laws and standards of my profession require that I keep treatment records and maintain them for seven years past your final date of treatment with me. I use an Electronic Health Record (EHR) for documentation and, we will discuss when applicable, billing. The systems I use for EHR documentation and billing are TheraNest and Office Ally both of which are HIPAA compliant, confidential systems. HIPAA provides you/your child with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what we can expect information from your Clinical Record is disclosed to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatment. It is important to remember others; requesting an accounting of most disclosures of protected health information that you always have neither consented to nor authorized; determining the location to which the protected information disclosures are sent; having any complaints that you/your child make about my policies and procedures recorded in your records; and the right to pay for a paper copy of this Agreement, the attached Notice form, and my services yourself to avoid these problems that compromise your full confidentialityprivacy policies and procedures.
Appears in 1 contract
Sources: Psychotherapy Services Agreement
Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangementotherwise. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay for services, you Returned checks are ultimately responsible subject to pay for services. Payment that is not made at the time of a session is expected within 30 days. I am happy to work with patients to arrange for payment plans if that becomes necessary$35 fee. If your account has not been paid for more than 60 days 90 days, and suitable arrangements for payment have not been agreed upon, I we have the option of suspending or discontinuing treatment, and/or using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court, which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a patient’s treatment is his/her name, dates, the nature of services provided, and the amount due. If such legal action becomes is necessary, the its costs will be included in the claim. In most collection situations, the only information I release regarding treatment is the client’s name, the nature of the services provided (i.e. individual psychotherapy), and the amount due. Initials (of Individual, couple or family) 3 In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I Warner & Associates, LLC does not participate with any insurance companies. We will fill out forms and provide you with whatever assistance I can in helping you receive benefits an invoice to which you are entitled; however, you (not submit to your insurance company) are responsible company or flexible spending account for full payment of my feesreimbursement, according to your individual health insurance plan benefits. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I we will provide you with whatever information I we can based on my experience our experience, and will be happy to attempt to help you in understanding the information you receive from required by your insurance companycompany for reimbursement. If it is necessary to clarify benefitYOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA FORM DESCRIBED ABOVE. _______________________________________________ Client Name _______________________________________________ Client Signature (if 18 or over) _______________________________________________ ___________________ Parent/Guardian Name (if applicable) Date _______________________________________________ Parent/Guardian Signature (if applicable) _______________________________________________ ____________________ Warner & Associates, LLC Staff Name Date _______________________________________________ Warner & Associates, LLC Staff Signature I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems acknowledge that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I am required to relate additional clinical information such as treatment plans or summaries, or copies of your entire record (in rare cases). This information will become part of the insurance company’s files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some casesreceived, they may share have read, and understand the information with a national medical databank“General Information and Psychological Services Agreement.” I have had my questions answered adequately at this time. I will provide you with a copy of any report understand that I submit, if you request it. Once we have all the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatment. It is important to remember that you always have the right to ask questions throughout the course of my assessment and/or treatment and may request an outside consultation. I also understand that the mental health provider may offer additional information about specific treatment issues and treatment methods on an as- needed basis during the course of my treatment or evaluation, and that I have the right to consent to or refuse such treatment. I understand that I can expect regular review of treatment to determine whether treatment goals are being met. I agree to be actively involved in the treatment, and in the review process. No promises have been made as to the results of this treatment or evaluation, or of any procedures utilized within it. I further understand that I may stop my treatment or evaluation at any time, but agree to discuss this decision first with my mental health provider. My only obligation, should I decide to stop treatment, is to pay for the services I have already received, and to attend one final session to discuss my services yourself reasons and to avoid terminate. I have been informed that I must give 24 hours notice to cancel an appointment, and that I will be charged $80 if I do not cancel or show up for a scheduled session. I am aware that I must authorize the mental health provider in writing to release information about my treatment, but that confidentiality can be broken under certain circumstances of danger to myself or others. I understand that once I release information to insurance companies or any other third party, there is no guarantee that it will remain confidential. My signature signifies my understanding and agreement with these problems that compromise your full confidentiality.issues, and with the additional information conveyed in this statement. Client Name Date Client Signature (if 18 or over) Patient/Guardian Name (if applicable) Date Patient/Guardian Signature (if applicable) Warner & Associates, LLC Staff Name Date Warner & Associates, LLC Signature Form completed by: __________________________________________ Relationship to child: Date: ____ Child’s Full Name: M / F Address: __________________________________________________________________________________ City/State: Zip: Age: _______ Date of Birth: ______/ ______/______ Grade in School: __________ GPA: ___________ Ethnic Identification: African American/Black ______ American Indian/Native American ______ Asian-American/Pacific Islander ______ Caucasian/White ______ Latino/Hispanic ______ Biracial/Multiracial ______ Other: ___________________________ Parental Marital Status: _____ Never Married _____ Separated Widowed _____ Married _____ Divorced Other Is custody being disputed in any legal action? Yes No Parents are: _____ Birth parents ▇▇▇▇▇▇ parents _____ Adoptive parents Other Who has physical custody? ________________________ Legal custody? ________________________ Address (if different from above): __________________________________________________________ City/State: , Zip: Phone: Home( ) Work( ) ________ Cell(_____)________________
Appears in 1 contract
Sources: General Information and Psychological Services Agreement
Billing and Payments. You will be expected to pay for each session services at the time it is heldthey are rendered, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay for services, you are ultimately responsible to pay for services. Payment that is not made at the time of a session is expected within 30 days. I am happy to work with patients to arrange for payment plans if that becomes necessaryotherwise. If your account has not been paid for more than 60 45 days and arrangements for payment have not been agreed upon, I have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action becomes necessary, the costs court which will be included in the claimrequire me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is the client’s his/her name, the nature of the services provided (i.e. individual psychotherapy)provided, and the amount due. Initials (of IndividualIf such legal action is necessary, couple or family) 3 those costs will be included in the claim. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatmenttreatment and/or testing. While I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is therefore very important that you find out exactly what mental health the extent to which my services are reimbursable through your insurance policy coverscompany. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administratoradministrator or human resources consultant. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefit, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that most your contract with your health insurance companies company may require you to authorize me to that I provide them with a information relevant to the services that I provide to you in order for you to obtain reimbursement. Your account statement provides the information most commonly requested (e.g., clinical diagnosis. Sometimes I am required to relate diagnoses, CPT codes, date of service, etc.) Your health insurance company may request additional clinical information such as treatment plans or summaries, or even copies of your entire record (in rare cases)although this is not common.) In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested and only upon your request. This information will become part of the insurance company’s company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. Once we have all the By signing this Agreement, you agree that I can provide requested information about to your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatmentcompany. It is important to remember that you always have the right to pay for my services yourself to avoid these the problems that compromise described above (unless expressly prohibited by your full confidentialityinsurance policy.) Paying for my services yourself provides maximal privacy protection and control over the services you receive.
Appears in 1 contract