Common use of Billing and Payments Clause in Contracts

Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise. I accept cash or checks. Other professional services payments will be agreed to at the time of the request. Receipts for therapy will be sent to you if requested. If you choose to turn the receipt over to an insurance company or a third party payer, I CANNOT CONTROL THE SECURITY OF YOUR RECORDS. Remember your receipt often contains a diagnosis. Also insurance companies often require your entire, otherwise protected file. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the legal option of using customary means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the general nature of services provided, and the amount due. The laws and standards of my profession require that I keep treatment records. Pursuant to HIPPA, I keep a Protected Health Information (PHI) record which includes information about your reasons for seeking treatment, the way your presenting problem impacts your life, your diagnosis, the goals we set for treatment, your progress towards those goals, your medical and social history, treatment history, and your billing/insurance records. As it states in the Confidentiality Section of this form, I will not release your PHI without your written permission unless in falls into the legal exceptions. PLEASE READ THE CONFIDENTIALITY SECTION OF THIS FORM VERY CAREFULLY. You have the right to obtain your PHI as well as provide me with a written request to amend your PHI. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in my presence so that we can discuss the contents. I am sometimes willing to conduct a review meeting without charge. I also will be happy to send your records to a mental health professional of your choice after you have signed a written release form. Patients will be charged an appropriate fee for any time spent in preparing information requests. If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for your parents, and we will discuss it before I send it to them.

Billing and Payments. You will be expected are responsible for coming to pay for each your session on time and at the time it is heldwe have scheduled. If you are using insurance, unless your insurance will not cover the session if you are 15 minutes late. Therefore, you would be responsible for the session fee of $100. If you are late, we agree otherwisewill end on time and not run over into the next person's session. I accept cash or checksClients must provide the therapist a minimum of 24 hours notice in the event they will miss a session. Other professional services payments Sessions cancelled with less than 24 hours advanced notice will be agreed charged $50 to the client. If you miss a session without cancelling (no show), you must pay $50 before another appointment can be scheduled. If you are using insurance your insurance company will not pay for missed sessions or late cancellation fees. Your signature on the “Acknowledgment of Notifications” form indicates that you agree to the terms of this policy and you agree to make prompt payment (at the time of the requestoriginal scheduled appointment) on the charge incurred for a late cancellation/missed appointment. Receipts Repeated “no-show” appointments could result in referring you to another practitioner. All payments are due at the time of service and are to be paid in full unless we agree otherwise or unless you have insurance coverage which requires another arrangement. My fee for therapy a session is $100.00. If we decide to meet for a longer session, I will bill you prorated on the hourly fee. Payment schedules for other professional services will be sent agreed to you if when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. I charge a fee of $50 for returned checks. I request that all individuals maintain a credit card on file in the event of an unforeseen balance developing. Because I never wish to take my clients to small claims court or turn their accounts over to collections agencies, I work to prevent balances by requiring a credit card on file. You will be notified before the card is charged in the event that a balance has developed due to insurance not covering your services and you have the option of making alternative payment arrangements if this happens. In the event of a missed appointment (late cancelation or no-show), your card will be charged at the time of the missed appointment. This policy also helps protect me from the unfortunate experience of not being paid for my time and expertise in providing services to you. It is my policy that any patient balances must be paid at the time of services or you will be required to reschedule your appointment when the balance has been paid. This may mean not being seen at the time of your appointment if you have not made your payment and will result in a late cancellation fee since I have set aside that appointment time only for you. True emergency situations will be evaluated on a case-by-case basis, as I do understand that emergencies can arise. Payments by cash, check or debit card at time of service, payable to: ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇, LCSW, are acceptable. Please note: If you choose owe the equivalent of two sessions charges, a new appointment will not be made until after payment of the outstanding balance, at least in part, is received by my office. In addition, if your balance is not paid in full within 30 days, a $35 late fee will be added to turn the receipt over to an insurance company or a third party payer, I CANNOT CONTROL THE SECURITY OF YOUR RECORDS. Remember your receipt often contains a diagnosis. Also insurance companies often require your entire, otherwise protected filebalance. If your account has not been paid for more than 60 30 days and arrangements for payment have not been agreed upon, I have the legal option of using customary legal means to secure the payment. This If I terminate services, I will provide you with 3 referral sources. Legal means may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its it’s costs will be included in the claim. In most collection situations, the only information I release regarding a patientclient’s treatment is his/her name, the general nature of services provided, and the amount due. The laws and standards Some insurance companies have products that will reimburse you for therapy. I will provide any documentation needed for you to gain reimbursement from your insurance company. I am not willing to have clients run a bill with me. I cannot accept barter for therapy. You are responsible for your bill, co-payment, or deductible payment at the time of service. It is very important that you find out exactly what mental health services your insurance policy covers to prepare yourself for the financial expense of treatment. Some of my profession require that I keep treatment recordsclients elect to use their insurance to help pay for our time together. Pursuant If you decide to HIPPA, I keep a Protected Health Information (PHI) record which includes information about involve your reasons for seeking treatment, the way insurance company in your presenting problem impacts your life, your diagnosis, the goals we set for treatment, your progress towards those goals, your medical and social history, treatment history, and your billing/insurance records. As it states in the Confidentiality Section of this formservices, 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 release your PHI without insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your written permission unless insurance policy covers. But, before deciding to use your insurance coverage, please read the following four paragraphs very carefully so you will know how filing for insurance may affect you. Filing for third party reimbursement requires that your services, or “treatment,” be certified as “medically necessary.” This requires your therapist provide the insurance company with a diagnosis to justify your treatment. It is my understanding that you will have this diagnosis attached to your insurance records for a number of years to come. It is also my understanding that this diagnosis, and possibly other personal information about you and your therapy services, will be kept in falls into shared insurance computers for some period of time. The diagnosis may lead to your being uninsurable for underwritten insurance (e.g., disability, life, health, etc.) for a number of years. If your insurance is a managed care policy, as most insurance policies are today, I may be required to send the legal exceptionsinsurance company much personal information about you in addition to the mental health diagnosis. PLEASE READ THE CONFIDENTIALITY SECTION OF THIS FORM VERY CAREFULLYI may also be required to write frequent reviews releasing more personal information with each review. I cannot guarantee that this information will be treated confidentially once it is released and out of my hands. Also, managed care policies usually limit the frequency of psychotherapy appointments and the total number of sessions they consider necessary to treat your diagnosis. As noted earlier, insurance companies will not pay for missed appointments, whether no-shows or late cancellations. You are responsible for paying for the reserved time. Your appointments are set aside exclusively for you and if/when you do not show up, that time still belongs to you. By signing the “Acknowledgment of Notifications” form, you agree that ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇, LCSW can provide requested information to your carrier, should you decide to involve your insurance company in your services. Remember, you have the right to obtain pay privately for your PHI psychotherapy and leave this third party out of your confidential relationship with your provider. This outlines my office policies related to use of Social Media. Please read it to understand how I conduct myself on the Internet as well as provide me with a written request to amend your PHI. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in my presence so that we can discuss the contents. I am sometimes willing to conduct a review meeting without charge. I also will be happy to send your records to a mental health professional of your choice after and how you have signed a written release form. Patients will be charged an appropriate fee for any time spent in preparing information requestscan expect me to respond to various interactions that may occur between us on the Internet. If you are under eighteen years of agehave any questions about anything within this document, please I encourage you to bring them up when we meet. As new technology develops and the Internet changes, there may be aware that the law may provide your parents the right times when I need to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your recordsupdate this policy. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this casedo so, I will notify them you in writing of my concernany policy changes and make sure you have a copy of the updated policy. Friending I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I will believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also provide blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it. Interacting Please do not use messaging on Social Networking sites such as Twitter, Facebook, or LinkedIn to contact me. These sites are not secure and I may not read these messages in a timely fashion. Do not use Wall postings, @replies, or other means of engaging with me in public online if we have an already established client/therapist relationship. Engaging with me this way could compromise your confidentiality. It may also create the possibility that these exchanges become a summary part of your treatment when it legal medical record and will need to be documented and archived in your chart. If you need to contact me between sessions, the best way to do so is completeby phone. Before giving them any informationDirect email at ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇.▇▇▇ is second best for quick, I will discuss administrative issues such as changing appointment times. See the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together email section below for your parents, and we will discuss it before I send it to themmore information regarding email interactions.

Billing and Payments. You We accept credit cards, debit cards, HSA cards, and FSA cards. No checks or cash are accepted. Before scheduling your first session, information for an active credit, debit, HSA, or FSA card is required and will be expected truncated and securely stored by a third-party bankcard processor, Pineapple Payments/CardConnect, to pay meet Payment Card Industry (PCI) requirements. Please be advised that your card for each session at will be charged after the time it is held, session has been held unless we agree otherwise. I accept cash or checks. Other Payment schedules for other professional services payments will be agreed to at the time of the request. Receipts for therapy will be sent to you if when such services are requested. Any charges will show up on your financial statement (e.g., credit card statement) as “DC Services”. If payment after a session is not received for any reason, we will notify you choose of this and further sessions will not be scheduled until the balance is paid in full. If your credit, debit, HSA, or FSA card on file has expired, we require you to turn the receipt over to replace it with an insurance company or a third party payer, I CANNOT CONTROL THE SECURITY OF YOUR RECORDS. Remember active card before your receipt often contains a diagnosis. Also insurance companies often require your entire, otherwise protected filenext session is scheduled. 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 legal option of using customary legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessarythis should occur, its costs costs, including court costs, reasonable attorney fees, and prejudgment interest on unpaid fees, will be included in the claim. In most collection situations, the only information I we will release regarding a patient’s treatment is his/her name, the general dates, times, and nature of services provided, and the amount due. The laws and standards of my profession require that I keep treatment recordsYour scheduled time is reserved for you. Pursuant to HIPPA, I keep a Protected Health Information (PHI) record which includes information about your reasons for seeking treatment, the way your presenting problem impacts your lifeIf you arrive late, your diagnosissession will likely be shortened by that amount of time and you are still responsible for paying the full session fee. Please try to arrive punctually to get the full benefit of your session. T elehealth Sessions Depending on the circumstance, we might offer telehealth sessions which are sessions conducted by telephone or video. This would be charged at the goals we set regular rate. Please be aware that the procedure code for treatmenttelehealth services are different than for an in-office appointment and insurance coverage may not be available depending on your particular plan. It is your responsibility to clarify this in advance with your insurance carrier. C ancellations For first-time new patients, cancellations and rescheduled initial evaluations will not be subject to any fee. If, however, as a first-time new patient you canceled or rescheduled the initial evaluation without notifying us at least 24 hours before the start of the appointment time, or you no-showed (i.e., you did not come to your progress towards those goalsappointment and did not provide any notification that you were not coming), your medical you will be subject to the full fee of the initial evaluation ($395) for any subsequent initial evaluation(s) you schedule and social historythen no-show or cancel or reschedule without notifying me at least 24 hours before the start of the appointment time. For existing patients, treatment historyno-shows, cancellations, and rescheduled sessions will be subject to a full charge of the session fee if we were not provided notification at least 24 hours before the start of the appointment time. It is your billing/insurance recordsresponsibility to ensure we have received your cancellation or rescheduling request which you may do by telephone, email, or in-person communication. As it states We will provide you notification as soon as we can whether we will be able see patients in the Confidentiality Section office on inclement weather days. Even if we come to the office to see patients, if you no-show, cancel, or reschedule your appointment less than 24 hours of the start time of the appointment and the reason is due to inclement weather, no fee will be charged. In the case of inclement weather, we typically offer telehealth sessions charged at the regular rate and occurring at your regularly scheduled appointment time but we cannot guarantee this form, I will be an option. We are often not immediately available by telephone or email since we will not release your PHI without your written permission unless in falls into answer the legal exceptions. PLEASE READ THE CONFIDENTIALITY SECTION OF THIS FORM VERY CAREFULLY. You have the right to obtain your PHI as well as provide me telephone or check emails when we are with a written request patient. When we are unavailable, please leave us a voicemail or an email message; we monitor both frequently. We will make every effort to amend return your PHI. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in my presence so that we can discuss message within 24 hours with the contents. I am sometimes willing to conduct a review meeting without charge. I also will be happy to send your records to a mental health professional exception of your choice after you have signed a written release form. Patients will be charged an appropriate fee for any time spent in preparing information requestsweekends and holidays. If you are under eighteen years of agedifficult to reach by telephone, please let us know some times when you will be available. Please note that face-to-face sessions are preferable to telehealth sessions. However, in the event that you are out of town, sick, or need additional support, telehealth sessions may be available and will be subject to a fee as described under FEES. If you are unable to reach us and feel that you cannot wait for us to return your call, contact your family physician, call 911, or go to the nearest emergency room. If we will be unavailable for an extended time, we will provide you with the name of a colleague to contact. E mail Communications and Text Messaging We use email communication and text messaging to send appointment reminders through our practice management system, SimplePractice. You may decline receiving these email and/or text message reminders at any time, and you may opt-in to receive voice reminders instead of or in addition to the email and text message reminders. Besides sending appointment reminders via text message, we do not send text messages to patients nor do we respond to text messages from anyone in treatment. For email communication besides the appointment reminders we send through SimplePractice, we also use SimplePractice to send emails regarding some administrative tasks such as notifying you when there is a new questionnaire to complete on your patient portal, or when you have a new superbill available to view on your patient portal. For emails that do not go through SimplePractice, we have made all attempts to create an email account that is secure and HIPAA compliant. However, because email communication is at risk to be accessed by unauthorized people, it may compromise the privacy and confidentiality of the email. The telephone or face- to-face context is much more secure as a mode of communication. If you provide us an email address, we will assume you are agreeing that we can communicate with you via email for non- sensitive matters such as scheduling or providing you a copy of your sleep log. We will not initiate an email exchange with you regarding sensitive matters such as your diagnosis and treatment details. However, if you initiate an email exchange with us regarding sensitive matters, then we will assume: (1) you have made an informed decision to do so and we will view it as your decision to take the risk that such information may be intercepted, and (2) you have granted us permission to respond to any questions you have asked us in that email back to you via email and we will view it as your decision to take the risk that any information we may include in my response may be intercepted. Furthermore, you should be aware that the law may provide all emails we receive from you and send to you are filed in your parents the right to examine patient chart and will thus become part of your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your recordslegal record. If they agreeyour personal contact information (e.g., I will telephone number, email address) changes, it is your responsibility to inform us of these changes as soon as possible so as not to miss appointment reminders, etc. We am not responsible for charges associated with such changes. P atient Portal Your secure patient portal is ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇/. From here, you can log in to (1) view your appointments, (2) request appointments, (3) review and complete documents we share with you, and (4) obtain copies of your invoices and superbills. Our practice management system, SimplePractice, maintains this patient portal. You can review SimplePractice’s privacy policy at ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/privacy/. W ebsite We have a website that you are free to access: ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. We use it for professional reasons to provide them only with general information to others about us and the practice. You are welcome to access and review the information that we have on our work togetherwebsite. S ocial Media We may participate on social networks but not in our professional capacity. If you have an online presence, unless I feel there is a high risk possibility that you will seriously harm yourself or someone elsemay encounter us by accident. In this case, I will notify them of my concern. I will also provide them with a summary Due to the importance of your treatment when it is complete. Before giving them confidentiality and the importance of minimizing dual relationships, we do not accept friend or contact requests or respond to any informationmessages from current or former patients on any social networking site (Facebook, I will discuss the matter with youLinkedIn, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for your parents, and we will discuss it before I send it to themetc.).

Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwiseotherwise or unless you have insurance coverage that requires another arrangement. I accept cash or cash, checks, Visa and MasterCard. Other professional services payments will be agreed to at the time In circumstances of the request. Receipts for therapy will be sent to you if requested. If you choose to turn the receipt over to an insurance company or a third party payerunusual financial hardship, I CANNOT CONTROL THE SECURITY OF YOUR RECORDSmay be willing to negotiate a fee adjustment or payment installment plan. Remember your receipt often contains Accounts are due 45 days after the date of service. Overdue accounts may be charged interest at a diagnosis. Also insurance companies often require your entire, otherwise protected filerate of 1.5% per month. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the legal option of using customary legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its 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 his/her name, the general nature of services provided, and the amount due. The laws If such action is necessary, its costs will be included in the claim. There are many different insurance plans and standards reimbursement options, and I am not able to keep track of my profession them all. It is your responsibility to know your level of coverage for services with me. I recommend all clients contact their insurance company to ask about plan coverage, co-pays, co-insurance, and deductibles, referencing ▇▇▇ ▇▇▇▇▇▇▇▇▇, PsyD, LP as your provider. If you elect to use your health insurance coverage, you should be aware that most insurance companies require that I provide them with your clinical diagnosis and dates of services for billing purposes. Sometimes, insurance companies request additional clinical information, such as treatment plans, progress notes or summaries, or copies of the entire records (in rare cases). Although all insurance companies claim to keep treatment records. Pursuant to HIPPAsuch information confidential, I keep a Protected Health Information (PHI) record which includes information about your reasons for seeking treatment, the way your presenting problem impacts your life, your diagnosis, the goals we set for treatment, your progress towards those goals, your medical and social history, treatment history, and your billing/insurance records. As have no control over what they do with it states once it is in the Confidentiality Section of this form, I will not release your PHI without your written permission unless in falls into the legal exceptions. PLEASE READ THE CONFIDENTIALITY SECTION OF THIS FORM VERY CAREFULLYtheir hands. You have the right understand that, by using your insurance, you authorize me to obtain your PHI as well as provide me with a written request to amend your PHI. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in my presence so that we can discuss the contents. I am sometimes willing to conduct a review meeting without charge. I also will be happy to send your records to a mental health professional of your choice after you have signed a written release form. Patients will be charged an appropriate fee for any time spent in preparing necessary information requests. If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concerninsurance company. I will also provide them try to keep that information limited to the minimum necessary. A scheduled appointment means that time is reserved only for you. If an appointment is missed or cancelled with a summary less than 24-hours notice, you will be billed directly according to the scheduled fee or according to the rules of your treatment when it is completeinsurance plan. Before giving them any informationYour insurance plan does not cover payment for missed appointments; therefore, I you are responsible for payment in full. Repeated cancellations and missed appointments may result in termination of the therapeutic relationship. A letter reflecting termination will discuss the matter with you, if possible, and do my best be mailed to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for your parents, and we will discuss it before I send it to themshould this occur.

Billing and Payments. I accept cash and credit cards (there is a charge if you use credit card). You will be expected to pay for prior to each session at the time it is held, unless we agree otherwise. In circumstances of unusual financial hardship, I accept cash or checksmay be willing to negotiate a payment installment plan. Other professional services payments I will be agreed to at the time of the request. Receipts responsible for therapy will be sent to you billing your insurance company if requested. If you choose to turn the receipt over use this and you will be responsible for any co-pays or deductibles. You will be responsible for filing any out of network bills to an your insurance company or a third party payer, I CANNOT CONTROL THE SECURITY OF YOUR RECORDS. Remember your receipt often contains a diagnosis. Also insurance companies often require your entire, otherwise protected filecompany. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the legal option of using customary 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 I release regarding a client's treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. By signing this agreement, you grant permission for me to seek assistance in collecting unpaid fees. To avoid having me use legal means to secure payment, please communicate with me about any concerns that you have regarding your ability to pay. If therapy services are begun, I typically schedule one 45-60 minute session (one appointment hour for 45-53 minutes duration) per week, although some sessions may be longer or more or less frequent. An intake session may last 1 hours. Your appointment time is reserved for you. You will be expected to pay for it unless you provide 24 hours advance notice of cancellation, or unless we both agree that you were unable to attend due to circumstances beyond your control. My fee for therapy is $175 per 45-60 minute hour and $225.00 for family sessions. These fees are to be paid prior to the session. The fee for initial intake session is $200.00. If there are special circumstances you would like for me to consider regarding these fees, you must discuss the circumstance with me prior to the first session. If you miss an appointment without notice or fail to call more than 24 hours in advance, you will be billed $120 for that time. In most collection situationsaddition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the only information I release regarding a patient’s hourly cost if we work for periods of less than one hour. Other services include classroom observations, report writing, telephone conversations lasting longer than 15 minutes, consulting with other professionals with your permission, preparation of records or treatment is his/her name, the general nature of services providedsummaries, and the amount due. The laws and standards of my profession require that I keep treatment records. Pursuant to HIPPA, I keep a Protected Health Information (PHI) record which includes information about your reasons for seeking treatment, the way your presenting problem impacts your life, your diagnosis, the goals we set for treatment, your progress towards those goals, your medical and social history, treatment history, and your billing/insurance records. As it states in the Confidentiality Section of this form, I will not release your PHI without your written permission unless in falls into the legal exceptions. PLEASE READ THE CONFIDENTIALITY SECTION OF THIS FORM VERY CAREFULLY. You have the right to obtain your PHI as well as provide me with a written request to amend your PHI. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in my presence so that we can discuss the contents. I am sometimes willing to conduct a review meeting without charge. I also will be happy to send your records to a mental health professional of your choice after you have signed a written release form. Patients will be charged an appropriate fee for any time spent in preparing information requests. If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them performing any information, I will discuss the matter with you, if possible, and do my best to handle any objections other service you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for your parents, and we will discuss it before I send it to them.request of

Billing and Payments. You will be expected to pay for each session at the time it is held. In circumstances of unusual financial hardship, unless we agree otherwiseI may be willing to negotiate a fee adjustment or payment plan. This adjustment and/or payment plan would be agreed upon in advance, at the outset of treatment. I accept cash do not renegotiate fees once the treatment process has begun. Payments may be made by cash, check, or checkscredit card (including health savings account credit cards). Other professional services payments will Credit cards are processed through a PCI-compliant hosting provider. In the event that a check is issued as payment and it is returned by the bank due to insufficient funds, you may be agreed to at the time of the request. Receipts for therapy will be sent to you if requested. If you choose to turn the receipt over to an insurance company or assessed with a third party payer, I CANNOT CONTROL THE SECURITY OF YOUR RECORDS. Remember your receipt often contains a diagnosis. Also insurance companies often require your entire, otherwise protected file$25 processing fee. If your account has not been paid for more than 60 90 days and arrangements arrangement for payment have has not been agreed upon, I have the legal option of using customary legal means to secure the payment. This may involve my hiring a an attorney, collection agency or going through small claims court. If such legal action In the event that your account is necessaryreferred to an attorney, its collection agency or small claims court, you will also be responsible for actual collection costs will be included in the claimincurred, including all attorney’s fees and court costs. In most collection situations, the only information I release regarding a patientclient’s treatment is his/her name, the general nature of services provided, and the amount due. The laws and standards If your account remains unpaid after 90 days, you can be assessed with additional account charges at the rate of my profession require that 1.5% per month (18% annually). I keep treatment recordsmay deny subsequent services if your account remains unpaid. Pursuant Because the appointment time is reserved for you, you are required to HIPPA, I keep a Protected Health Information (PHI) record which includes information about your reasons for seeking treatment, the way your presenting problem impacts your life, your diagnosis, the goals we set for treatment, your progress towards those goals, your medical and social history, treatment history, and your billing/insurance records. As it states in the Confidentiality Section of this form, I will not release your PHI without your written permission unless in falls into the legal exceptions. PLEASE READ THE CONFIDENTIALITY SECTION OF THIS FORM VERY CAREFULLY. You have the right to obtain your PHI as well as provide me with a written request full 24 hours notice if you need to amend cancel a scheduled appointment. Failure to provide me with the 24 hour notice or not showing up for an appointment will result in your PHIbeing billed at your regular session rate ($225 or the sliding scale fee that was agreed upon at the outset of treatment). Because these are professional records, they can Please note that cancellations for Monday sessions must be misinterpreted and/or upsetting to untrained readersreceived by the end of the business day on Friday (5 PM). I recommend have created this policy for two reasons: 1) to allow me adequate time to fill in cancellations with other individuals who are in need of my services; 2) to protect against financial loss associated with appointment no-shows or last-minute cancellations. While I have the utmost of empathy for both the usual and unusual life events that you review them can arise which may precipitate the need for an appointment cancellation, this policy exists because my professional livelihood is based on services rendered over a finite period of time. If a cancellation occurs at the last minute, regardless of the compelling reason, this lost professional time cannot be recouped. Unlike a medical doctor, for whom multiple patients are scheduled in my presence so that we can discuss the contentsbrief time slots, I have only a limited amount of time slots available per day for appointments, which cannot be filled with other patients when a last-minute cancellation occurs. I am sometimes willing to conduct a review meeting without charge. I also will be happy to send your records discuss any questions or reactions you may have to a mental health professional of your choice after you have signed a written release form. Patients will be charged an appropriate fee for any time spent in preparing information requests. If you are under eighteen years of agethis cancellation policy, but please be aware that when you sign this document you are indicating your consent to this policy and its terms. When I am unavailable, my telephone is answered by voicemail. I usually return phone calls within one (1) business day, unless otherwise specified in the law may provide message. I will make every effort to return your parents call on the right same day you call, with the exception of weekends and holidays. When you call, please let me know the best times to examine return your treatment recordscall. It is my policy In an urgent situation, please either contact your family physician or go to request an agreement from parents that they agree to give up access to your recordsthe nearest hospital emergency room. If they agreeI will be unavailable for an extended time, I will provide them you with the name and contact information of a colleague to contact. You may contact me via e-mail, but only with general information about our work together, unless I feel there for scheduling purposes. Do not use email to address any clinical or urgent matters. This is a high risk that you will seriously harm yourself best done by phone or someone else. In this case, I will notify them of my concernin person. I will also provide them do not text patients, nor do I respond to texts from patients, so please do not use this method to communicate with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for your parents, and we will discuss it before I send it to themme.

Billing and Payments. You I accept credit cards, debit cards, HSA cards, and FSA cards. No checks or cash are accepted. Before scheduling your first session, information for an active credit, debit, HSA, or FSA card is required and will be expected truncated and securely stored by a third-party bankcard processor, Pineapple Payments/CardConnect, to pay meet Payment Card Industry (PCI) requirements. Please be advised that your card for each session at will be charged after the time it is held, session has been held unless we agree otherwise. I accept cash or checks. Other Payment schedules for other professional services payments will be agreed to at the time of the request. Receipts for therapy will be sent to you if when such services are requested. Any charges will show up on your financial statement (e.g., credit card statement) as “DC Services”. If you choose to turn the receipt over to an insurance company or payment after a third party payersession is not received for any reason, I CANNOT CONTROL THE SECURITY OF YOUR RECORDSwill notify you of this and further sessions will not be scheduled until the balance is paid in full. Remember If your receipt often contains a diagnosis. Also insurance companies often credit, debit, HSA, or FSA card on file has expired, I require you to replace it with an active card before your entire, otherwise protected filenext session is scheduled. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the legal option of using customary legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessarythis should occur, its costs costs, including court costs, reasonable attorney fees, and prejudgment interest on unpaid fees, will be included in the claim. In most collection situations, the only information I will release regarding a patient’s treatment is his/her name, the general dates, times, and nature of services provided, and the amount due. The laws Your scheduled time is reserved for you. If you arrive late, your session will likely be shortened by that amount of time and standards you are still responsible for paying the full session fee. Please try to arrive punctually to get the full benefit of my profession require that I keep treatment recordsyour session. Pursuant to HIPPAT elephone Sessions Depending on the circumstance, I keep might offer telephone sessions. This would be charged at the regular rate. Please be aware that the procedure code for this service is different than for an in- office appointment and insurance coverage may not be available depending on your particular plan. It is your responsibility to clarify this in advance with your insurance carrier. C ancellations For first-time new patients, cancellations and rescheduled initial evaluations will not be subject to any fee. If, however, as a Protected Health Information first-time new patient you canceled or rescheduled the initial evaluation without notifying me at least 24 hours before the start of the appointment time, or you no-showed (PHIi.e., you did not come to your appointment and did not provide any notification that you were not coming), you will be subject to the full fee of the initial evaluation ($395) record which includes information about your reasons for seeking treatmentany subsequent initial evaluation(s) you schedule and then no-show or cancel or reschedule without notifying me at least 24 hours before the start of the appointment time. For existing patients, the way your presenting problem impacts your lifeno-shows, your diagnosis, the goals we set for treatment, your progress towards those goals, your medical and social history, treatment historycancellations, and rescheduled sessions will be subject to a full charge of the session fee if I was not provided notification at least 24 hours before the start of the appointment time. It is your billing/insurance recordsresponsibility to ensure I have received your cancellation or rescheduling request which you may do by telephone, email, or in-person communication. As it states I will provide you notification as soon as I can whether I will be able see patients in the Confidentiality Section office on inclement weather days. Even if I come to the office to see patients, if you no-show, cancel, or reschedule your appointment less than 24 hours of the start time of the appointment and the reason is due to inclement weather, no fee will be charged. In the case of inclement weather, I typically offer telephone sessions charged at the regular rate and occurring at your regularly scheduled appointment time but I cannot guarantee this formwill be an option. I am often not immediately available by telephone or email. Though I am usually in my office between 8am and 3pm Monday through Friday, I will not release your PHI without your written permission unless in falls into answer the legal exceptions. PLEASE READ THE CONFIDENTIALITY SECTION OF THIS FORM VERY CAREFULLY. You have the right to obtain your PHI as well as provide me telephone or check emails when I am with a written request to amend your PHIpatient. Because these are professional recordsWhen I am unavailable, they can be misinterpreted and/or upsetting to untrained readersplease leave me a voicemail or an email message; I monitor both frequently. I recommend that you review them in my presence so that we can discuss will make every effort to return your message within 24 hours with the contents. I am sometimes willing to conduct a review meeting without charge. I also will be happy to send your records to a mental health professional exception of your choice after you have signed a written release form. Patients will be charged an appropriate fee for any time spent in preparing information requestsweekends and holidays. If you are under eighteen years of agedifficult to reach by telephone, please let me know of some times when you will be aware available. Please note that face-to-face sessions are highly preferable to telephone sessions. However, in the law event that you are out of town, sick, or need additional support, telephone sessions may provide your parents the right be available and will be subject to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your recordsa fee as described under FEES. If they agreeyou are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician, call 911, or go to the nearest emergency room. If I will be unavailable for an extended time, I will provide them only you with general information about our work togetherthe name of a colleague to contact. E mail Communications and Text Messaging I use email communication and text messaging to send appointment reminders through my practice management system, unless SimplePractice. You may decline receiving these email and/or text message reminders at any time, and you may opt-in to receive voice reminders instead of or in addition to the email and text message reminders. Besides sending appointment reminders via text message, I feel do not send text messages to patients nor do I respond to text messages from anyone in treatment. For email communication besides the appointment reminders I send through SimplePractice, I also use SimplePractice to send emails regarding some administrative tasks such as notifying you when there is a high new questionnaire to complete on your patient portal, or when you have a new superbill available to view on your patient portal. For emails that do not go through SimplePractice, I have made all attempts to create an email account that is secure and HIPAA- compliant. However, because email communication is at risk that to be accessed by unauthorized people, it may compromise the privacy and confidentiality of the email. The telephone or face- to-face context is much more secure as a mode of communication. If you will seriously harm yourself or someone else. In this caseprovide me an email address, I will notify them assume you are agreeing that I can communicate with you via email for non- sensitive matters such as scheduling or providing you a copy of my concernyour sleep log. I will also provide them not initiate an email exchange with a summary you regarding sensitive matters such as your diagnosis and treatment details. However, if you initiate an email exchange with me regarding sensitive matters, then I will assume: (1) you have made an informed decision to do so and I will view it as your decision to take the risk that such information may be intercepted, and (2) you have granted me permission to respond to any questions you have asked me in that email back to you via email and I will view it as your decision to take the risk that any information I may include in my response may be intercepted. Furthermore, you should be aware that all emails I receive from you and send to you are filed in your patient chart and will thus become part of your treatment when legal record. If your personal contact information (e.g., telephone number, email address) changes, it is completeyour responsibility to inform me of these changes as soon as possible so as not to miss appointment reminders, etc. Before giving them any informationI am not responsible for charges associated with such changes. P atient Portal Your secure patient portal is ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇/. From here, you can log in to (1) view your appointments, (2) in some cases, request appointments, (3) review and complete documents I will discuss the matter share with you, if possibleand (4) obtain copies of your invoices and superbills. My practice management system, SimplePractice, maintains this patient portal. You can review SimplePractice’s privacy policy at ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/privacy/. M y Website I have a website that you are free to access: ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. I use it for professional reasons to provide information to others about me and do my best practice. You are welcome to handle any objections access and review the information that I have on my website. S ocial Media I participate on social networks but not in my professional capacity. If you have an online presence, there is a possibility that you may have with what I am prepared encounter me by accident. Due to discuss. At the end importance of your treatmentconfidentiality and the importance of minimizing dual relationships, I will prepare a summary of our work together for your parentsdo not accept friend or contact requests or respond to any messages from current or former patients on any social networking site (Facebook, and we will discuss it before I send it to themLinkedIn, etc.).

Billing and Payments. You will be expected to pay for each session appointment at the time it is held, unless we agree otherwiseotherwise in writing. I accept cash If you have insurance, you are required to pay your copay or checks. Other professional services payments will be agreed to coinsurance at the time of the requestservice. Receipts We accept VISA, MasterCard, cash or checks for therapy will be sent to you if requestedpayment. There is a $30.00 charge for any returned checks. If the check is returned, we will no longer be able to accept checks from you choose to turn the receipt over to an insurance company or a third party payer, I CANNOT CONTROL THE SECURITY OF YOUR RECORDS. Remember your receipt often contains a diagnosis. Also insurance companies often require your entire, otherwise protected filefor payment. If your account has not been paid for more than 60 days by the statement due date and arrangements for payment have not been agreed uponmade, I we have the legal option of using customary legal means to secure the payment. This may involve hiring using a collection agency or going through small claims courtinitiating legal action in the court system. If such legal action is necessary, you expressly agree to be responsible for any associated costs, including attorney’s fees, filing fees, and other related expenses. If you do not have an insurance plan that will pay for our services, or if you elect not to submit our bill for services to your insurance provider, then we will charge you a flat fee of $150.00 for the initial assessment and thereafter at a rate of $125.00 per hour. (These rates are in effect at the time that the client signs this Service Agreement; however, nothing in this agreement precludes Brighter Futures from periodically changing its costs rates for service). Although the above quoted fees are in effect as a base rate for all clients, Brighter Futures may charge individual clients according to a Sliding Fee Scale based on the client’s income and number of dependents. If you have a bill with a balance that is more than 30 days past due, Brighter Futures Counseling, PLLC may turnover your account to an attorney or collection agency. The information given to the attorney/collection agency will be included in the claim. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the general nature of services providedprovided (for example, “therapy” or “subpoena for court appearance”) and the amount due. The laws , and standards of my profession require that I keep treatment records. Pursuant to HIPPA, I keep a Protected Health Information (PHI) record which includes will not include specific information about your reasons for seeking treatmentdiagnosis and/or medical or mental health history or condition. Any harassing communications, including offensive or abusive language, will not be tolerated on the premises of Brighter Futures Counseling or by telephonic or electronic communication. If a client or person associated with the client engages in such behavior, the way your presenting problem impacts your lifeoffending party will be asked to leave or, your diagnosisas appropriate, asked not to return to the goals we set for treatmentfacility. If this behavior persists and the offending party does not comply with requests to stop, your progress towards those goals, your medical and social history, treatment history, and your billing/insurance records. As it states in the Confidentiality Section of this form, I will not release your PHI without your written permission unless in falls into the legal exceptions. PLEASE READ THE CONFIDENTIALITY SECTION OF THIS FORM VERY CAREFULLY. You have Brighter Futures reserves the right to obtain your PHI as well as provide me with a written request to amend your PHI. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in my presence so that we can discuss call the contents. I am sometimes willing to conduct a review meeting without charge. I also will be happy to send your records to a mental health professional of your choice after you have signed a written release form. Patients will be charged an police or other appropriate fee for any time spent in preparing information requests. If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for your parents, and we will discuss it before I send it to themenforcement authority.

Billing and Payments. You will be If you are a self-pay client, you are responsible for the fees for your therapy, and are expected to pay for each session at the time it of the session unless other arrangements have been made. In the event that you encounter some unusual financial hardship, such as losing your job, I may be willing to negotiate a payment plan so you can continue receiving therapy during the difficult time. If I am an in-network provider with your insurance program, I will gladly verify your benefits for you and bill insurance. Based on your benefits, you may be responsible for some or all of the contracted fee for my services up front (i.e., may not have met your deductible, may have a copay, or may have co-insurance). Payment is helddue at the time of service. Please understand that I do everything I can to verify your benefits up front. However, unless in some instances, insurance companies indicate that the services I provide will be covered and then deny benefits later. By signing this services agreement, you are agreeing to leave an active credit card on file that I will bill in the event your insurance company declines to pay for the services you received. Whether you are self-pay or an insurance patient, if your balance due becomes very large, or if no payments are made for several months, I have the option of resorting to legal means to obtain payment if we agree otherwisecannot work out a payment plan. This could mean involvement of a collection agency or small claims court, and the cost of this collection effort would be passed on to you. Such efforts typically require disclosure of some otherwise confidential information, but we will limit this to the minimum information necessary. I accept cash or (but cannot make change), checks. Other professional services payments will be agreed to at the time of the request. Receipts for therapy will be sent to you if requested, and most major credit, debit, and HSA cards. If you choose to turn the receipt over to an insurance company use a card instead of cash or a third party payercheck to pay your bill, I CANNOT CONTROL THE SECURITY OF YOUR RECORDS. Remember your receipt often contains a diagnosis. Also insurance companies often require your entire, otherwise protected file. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the legal option of using customary means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs you will be included in assessed an additional 3% swipe fee. You can avoid this fee by paying at the claimtime of your appointment by cash or check. In most collection situations, the only information I release regarding _______ Initial here to accept a patient’s treatment is his3% processing fee when using your credit/her name, the general nature of services provided, and the amount duedebit/HSA card for payments. The laws and standards of my profession require that I keep treatment records. Pursuant to HIPPA, I keep Returned checks will incur a Protected Health Information (PHI) record which includes information about your reasons for seeking treatment, the way your presenting problem impacts your life, your diagnosis, the goals we set for treatment, your progress towards those goals, your medical and social history, treatment history, and your billing/insurance records$25 returned check fee. As it states in the Confidentiality Section previously noted, no-shows and late cancellations will be billed at a rate of this form, I will not release your PHI without your written permission unless in falls into the legal exceptions$125. PLEASE READ THE CONFIDENTIALITY SECTION OF THIS FORM VERY CAREFULLY. You have the right _______ Initial here to obtain your PHI as well as provide me with a written request to amend your PHI. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend acknowledge that you review them in my presence so that we can discuss are giving me permission to use the contents. I am sometimes willing card on file to conduct a review meeting without charge. I also will be happy to send your records to a mental health professional of your choice after you have signed a written release form. Patients will be charged an appropriate fee for any time spent in preparing information requests. If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, collect late cancellation/no-show fees and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for your parents, and we will discuss it before I send it to themreturned check fees.

Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwiseotherwise or unless you have insurance coverage that requires another arrangement. I accept cash or checks. Other Payment schedules for other professional services payments will be agreed to at when they are requested. Should this account become delinquent and sent for collection, any reasonable legal fees, court costs, collection agency fees, or any associated costs, fees or penalties will be added to the time balance. It is understood that in the event your portion of the request. Receipts for therapy balance due becomes 90 days or more delinquent, a late fee of $15.00 per month will be sent to charged until the amount you if requestedowe is paid in full. If you choose to turn the receipt over to an insurance company or There will be a third party payer, I CANNOT CONTROL THE SECURITY OF YOUR RECORDS. Remember your receipt often contains a diagnosis. Also insurance companies often require your entire, otherwise protected file$15.00 charge on all returned checks. If your account has not been paid for more than 60 90 days and arrangements for payment have not been agreed upon, I have the legal option of using customary legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its 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 his/her name, the general nature of services provided, and the amount due. The laws and standards of my profession require that I keep treatment records. Pursuant to HIPPA[If such legal action is necessary, I keep a Protected Health Information (PHI) record which includes information about your reasons for seeking treatment, the way your presenting problem impacts your life, your diagnosis, the goals we set for treatment, your progress towards those goals, your medical and social history, treatment history, and your billing/insurance records. As it states its costs will be included in the Confidentiality Section of this form, I will not release claim.] You are responsible for obtaining prior authorization for treatment from your PHI without your written permission unless in falls into the legal exceptions. PLEASE READ THE CONFIDENTIALITY SECTION OF THIS FORM VERY CAREFULLY. You have the right to obtain your PHI as well as provide me with a written request to amend your PHI. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in my presence so that we can discuss the contentsinsurance carrier. I am sometimes willing to conduct a review meeting without chargebill your insurance; however, you (not your insurance company) are responsible for full payment of my fees. I also Therefore, it is very important that you find out exactly what mental health services your insurance policy covers. Co-payment amounts are set by your benefit plan. These payments are due and payable at each appointment. Information regarding the co-payments set by your insurance plan for each visit will be happy provided to send you or you may contact your records to a mental health professional plan for this information. For special modalities of treatment not covered by your choice after you have signed benefits plan, a written release formagreement needs to be signed between you and this office/practitioner. Patients This agreement should outline your understanding that it is not a covered benefit and will be charged an appropriate fee for also cover the agreed fees and treatment plan you may expect. At any time spent in preparing information requests. If during treatment should you are under eighteen years of agebecome ineligible for insurance coverage, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I notify the practitioner and understand you will notify them become responsible for 100% of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for your parents, and we will discuss it before I send it to thembill.

Billing and Payments. You 9.1 How often will be expected to pay for each session at the time it is heldwe bill you? We will bill you on a regular basis (either in advance or in arrears), unless otherwise set out in the service description. 9.2 What will appear on your bill? (a) We will try to include on your bill all charges for the relevant billing period. However, this is not always possible and we agree otherwise. I accept cash or checks. Other professional services payments will may include these unbilled charges in a later bill(s). 9.3 We may use a billing agent to bill you We may bill you using a billing agent (which may be agreed to at the time another Next Generation Voice Pty Ltd group company). 9.4 What types of payment methods may you use? (a) You may pay by one of the request. Receipts for therapy will be sent to payment methods as set out in the “Payment Options” section of your bill or on our websites. (b) Unless you pay by direct debit we may charge a payment processing fee if requested. If you choose to turn use a credit, charge or debit card to pay your bill. 9.5 When must you pay your bill? Subject to clause 10.2, you must pay the receipt over entire amount billed by the due date specified in the payment notification, bill or as otherwise notified by us. 9.6 What happens if you do not pay your bill by the due date? If you do not pay your bill by the date the payment is due, we may: (a) charge you a late fee. You should see the relevant standard pricing table for the service concerned to an insurance company check the late fee that applies; (b) suspend or a third party payercancel the service, I CANNOT CONTROL THE SECURITY OF YOUR RECORDS. Remember your receipt often contains a diagnosis. Also insurance companies often require your entire, otherwise protected filein accordance with clause 11 or 12 as relevant or the relevant service description. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed uponwe suspend or cancel the service, I have the legal option of using customary means to secure the payment. This we may involve hiring charge you a collection agency suspension fee or going through small claims courtcancellation fee. If such legal action the service is necessary, its costs will be included in the claim. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the general nature of services provided, cancelled and the amount due. The laws and standards of my profession require that I keep treatment records. Pursuant to HIPPAservice disconnected or deactivated, I keep a Protected Health Information (PHI) record which includes information about your reasons for seeking treatment, the way your presenting problem impacts your life, your diagnosis, the goals we set for treatment, your progress towards those goals, your medical and social history, treatment history, and your billing/insurance records. As it states in the Confidentiality Section of this form, I will not release your PHI without your written permission unless in falls into the legal exceptions. PLEASE READ THE CONFIDENTIALITY SECTION OF THIS FORM VERY CAREFULLY. You have the right to obtain your PHI as well as provide me with a written request to amend your PHI. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in my presence so that we can discuss the contents. I am sometimes willing to conduct a review meeting without charge. I also will be happy to send your records to a mental health professional of your choice after you have signed a written release form. Patients will be charged an appropriate fee for any time spent in preparing information requests. If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with to pay a reconnection or reactivation fee for the reconnection or reactivation of the service. You should see the relevant standard pricing table for the service concerned to check what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for your parentsfees apply, and if fees do apply, what that fee is; (c) engage a mercantile agent to recover the money you owe us. If we engage a mercantile agent, we may charge you a recovery fee; (d) institute legal proceedings against you to recover the money you owe us. If we institute legal proceedings, we may seek to recover our reasonable legal costs reasonable incurred; and (e) on-sell any unpaid amounts to a third party. If we do this, any outstanding amounts will be payable to that third party. 9.7 What happens if you have overpaid as a result of a billing error? If you have overpaid as a result of a billing error: (a) your account will be credited with the amount you have overpaid, or (b) if you have stopped obtaining the service, we will discuss it before I send it use reasonable endeavours to themnotify you that you have overpaid and refund the over payment.

Billing and Payments. You will be expected to pay for each session at the time it is held, unless we you and your therapist agree otherwiseotherwise or unless you have insurance coverage, which requires another arrangement. I accept cash or checks. Other Payment schedules for other professional services payments will be agreed to at the time of the request. Receipts for therapy will be sent to you if when they are requested. If you choose In circumstances of unusual financial hardship, your therapist may be willing to turn the receipt over to an insurance company negotiate a fee adjustment or a third party payer, I CANNOT CONTROL THE SECURITY OF YOUR RECORDS. Remember your receipt often contains a diagnosis. Also insurance companies often require your entire, otherwise protected filepayment installment 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 legal option of using customary legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I we release regarding a patientclient’s treatment is his/her name, the general nature of services provided, and the amount due. The laws Therapist utilize varying forms to accept payment such as cash, credit card, personal checks, and standards mobile payment applications. I have provided my therapist with my current credit card number and authorize him or her to keep my signature on file, and to charge my credit card account for any outstanding balances, missed appointments, and services rendered when applicable. I understand that my credit card will only be charged when other arrangements have not been made and payment has not been received within thirty (30) days. I give my therapist consent to charge this credit card when applicable. In the unlikely event that I would dispute these charges, I agree not to take action with my credit card issuer without first contacting and speaking with my therapist to resolve the payment concern. A copy of the front and back of my profession credit card will be made and kept in my confidential client file. I consent to provide updated credit card information if this card should expire or be cancelled. Cardholder Name: Credit Card Type: Card Number: Expiration Date: CVV# (3 Digit Security Code): Billing Zip Code: Authorized Signature: Date: In order for us to set treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. We will provide you with whatever assistance we can in helping you receive benefits; however, you (not your insurance company) are responsible for full payment of 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. We can provide you with information based on our experience with other clients and try to help you understanding the information you receive from your insurance company but this should not replace policies or information provided by your insurance provider. Managed Health Care plans such as HMOs and PPOs often require 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. It is important to understand that while a lot can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits have ended. Some managed-care plans will not allow us to provide services to you once your benefits have ended. If this is the case, we will do our best to find another provider who will help you continue your therapy. You should also be aware that most insurance companies require that I we provide them with a clinical diagnosis. Sometimes we have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep treatment recordssuch information confidential, we have no control over what they do with it once it is in their hands. Pursuant In some cases, they may share the information with a national medical information databank. Your therapist can provide you with a copy of any reports they submit, if you request it. Not all therapist accept insurance or participate in health insurance panels. Some therapist may provide “out-of-network” services. In these instances, they can provide you with a receipt of payment which you may then use to HIPPA, I keep file a Protected Health Information (PHI) record which includes information about your reasons claim for seeking treatment, the way your presenting problem impacts your lifeout-of- network benefits. However, your diagnosis, therapist is not required to file the goals we set claims for treatment, your progress towards those goals, your medical and social history, treatment history, and your billing/insurance recordsout-of-network services in place of the client. As it states in the Confidentiality Section of this form, I will not release your PHI without your written permission unless in falls into the legal exceptions. PLEASE READ THE CONFIDENTIALITY SECTION OF THIS FORM VERY CAREFULLY. You It is important to remember that you always have the right to obtain your PHI as well as provide me with a written request pay for services yourself to amend your PHI. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readersavoid the issues described above. I recommend that you review them in choose NOT to utilize my presence so that we can discuss the contents. I am sometimes willing to conduct a review meeting without charge. I also will be happy to send your records to a mental health professional of your choice after you have signed a written release form. Patients will be charged an appropriate fee for any time spent in preparing information requests. If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In insurance coverage at this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for your parents, and we will discuss it before I send it to themtime.

Billing and Payments. You Unless we agree otherwise or unless you have insurance coverage that requires another arrangement, you will be expected to pay for each session psychotherapy services within one month of receiving my bill. Alternatively, many patients prefer to pay for services at the time it end of each session. This often simplifies the billing process for both parties. At the end of each month I will provide you with a bill of any outstanding balance on your account. For psychological assessment, 50% of the total is helddue on the date that testing is initiated, unless we agree otherwisewith the remainder due on the date the test results are presented to you. I accept cash or checksPayment for court appearances and other services that are related to legal proceedings is due in advance of those services. Other Payment schedules for other professional services payments will be agreed to at the time of the request. Receipts for therapy will be sent to you if when they are requested. If you choose Any balance that is 30 days past due (i.e., 30 days past the statement date on which it appears) is subject to turn the receipt over to an insurance company or a third party payer, I CANNOT CONTROL THE SECURITY OF YOUR RECORDS. Remember your receipt often contains a diagnosis. Also insurance companies often require your entire, otherwise protected file% monthly interest charge. If your account has not been paid for more than 60 days past the statement date and arrangements for payment have not been agreed upon, I have reserve the legal option of using customary legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its 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 his/her name, the general nature of services provided, and the amount due. The laws You will be responsible for all court, attorney, and standards other fees incurred in attempts to collect outstanding balances over 60 days past due. If you pay by check and that check is not honored by your bank, our bank will charge us a fee. That charge will be passed on to you and you will be responsible for its payment. You (not your insurance company) are responsible for full payment of my profession require fees. It is very important that I keep treatment recordsyou find out exactly what mental health services your insurance policy covers. Pursuant If you wish to HIPPA, I keep a Protected Health Information (PHI) record which includes information about use your reasons for seeking treatment, the way your presenting problem impacts your life, your diagnosis, the goals we set health insurance to seek payment for treatment, I will ask you to fill out an authorization so that I can provide information to your progress towards those goalsinsurance company that will allow me to provide the information necessary to secure payment for the services I provide for you. This Authorization will be in effect for one year, your medical and social historybut can be revoked at any time. However, treatment history, and your billing/insurance records. As it states in the Confidentiality Section of this formif revoked, I will not release your PHI without your written permission unless in falls into the legal exceptions. PLEASE READ THE CONFIDENTIALITY SECTION OF THIS FORM VERY CAREFULLY. You continue to have the right to obtain forward information necessary to process claims for services already provided. You should carefully read the section in your PHI as well as provide me with a written request to amend your PHI. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend insurance coverage booklet that you review them in my presence so that we can discuss the contents. I am sometimes willing to conduct a review meeting without charge. I also will be happy to send your records to a describes mental health professional of your choice after you have signed a written release form. Patients will be charged an appropriate fee for any time spent in preparing information requestsservices. If you are under eighteen years of agehave questions about the coverage, please be aware that the law may provide call your parents the right to examine your treatment recordsplan administrator. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agreeOf course, I will provide them only you with general whatever information about our work together, unless I feel there is a high risk that can based on my experience and would be willing to assist you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of in understanding the information you receive from your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for your parents, and we will discuss it before I send it to theminsurance company.

Billing and Payments. You will be are expected to pay for each session at the time it is heldend of the session, unless we agree otherwiseotherwise or unless you have insurance that requires another arrangement. I accept cash or checks. Other Payment schedules for other professional services payments will be agreed to at the time of the request. Receipts for therapy will be sent to you if when these services are requested. If you choose to turn the receipt over to an insurance company or a third party payerIn circumstances of unusual financial hardship, I CANNOT CONTROL THE SECURITY OF YOUR RECORDSam willing to negotiate a fee adjustment or payment installment plan. Remember your receipt often contains a diagnosisI do not accept payment via credit or debit cards. Also insurance companies often require your entire, otherwise protected file. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed uponIn rare circumstances, I have the legal option of using customary legal means to secure the payment. This may involve : hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claimcourt (both of which require my disclosing otherwise confidential information). In most collection situations, the only information I release regarding a patientclient’s treatment is his/her name, the general nature of services provided, and the amount due. The laws and standards of my profession require that I keep treatment records. Pursuant to HIPPAIf such legal action is necessary, I keep a Protected Health Information (PHI) record which includes information about your reasons for seeking treatment, legal costs are included in the way your presenting problem impacts your life, your diagnosis, the goals we set for treatment, your progress towards those goals, your medical and social history, treatment history, and your billing/insurance recordsclaim. As it states in indicated above, after an appointment time is scheduled, you are expected to pay for the Confidentiality Section of this formappointment unless you provide advance notice 24 hours prior to your appointment time. If we both agree that you were unable to attend due to circumstances beyond your control (e.g., last-minute illnesses/injury; transportation disruption), I will not release charge for the session. Insurance companies do not provide reimbursement for canceled sessions. Based on my schedule, I might not be able to offer you an alternative appointment in the same week. In order for us to set realistic treatment goals and priorities, we will assess the resources available to pay for your PHI without treatment. Because I do not participate in managed care panels, I collect fees directly from clients. If your written permission unless in falls into the legal exceptions. PLEASE READ THE CONFIDENTIALITY SECTION OF THIS FORM VERY CAREFULLYhealth insurance reimburses you directly, I will complete required forms and required information. You have (not your insurance company) are responsible for full payment of my fees. Please carefully read the right section in your insurance coverage booklet that describes mental health services in order to obtain determine the extent of your PHI coverage. Your insurance plan administrator can answer any questions. Your accessing insurance coverage to pay for your psychotherapy requires that I provide information relevant to the services I provide to you. I am required to provide a clinical diagnosis as well as provide me with a written request to amend your PHIall session dates. Because these are professional recordsI do not participate in managed care, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in my presence so that we can discuss the contents. I am sometimes willing to conduct a review meeting without charge. I also will be happy to send your records to a mental health professional do not provide additional clinical information such as treatment plans, treatment summaries, or copies of your choice after entire Clinical Record. By signing this Agreement, you have signed a written release form. Patients will be charged an appropriate fee for any time spent in preparing agree that I can provide the following specific requested information requests. If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agreeinsurance carrier: your name, I will provide them only with general information about our work togetherclinical diagnosis, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this casetreatment dates, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possiblefees, and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for your parents, and we will discuss it before I send it to thempayments.

Billing and Payments. You It is the philosophy of CIP to make our services available to everyone. CIP's regular fee for service is $150 per session. However, fee adjustments, based on one's ability to pay, are available in order to make it possible for clients of all income levels to receive therapy. Your fee will be expected established at the initial session. Our policy is to collect all fees at the time services are rendered. Make checks out to "CIP." Sessions are 50 minutes and generally scheduled on a regular basis. Once arranged, your hour is held for you from week to week. There is no 24-hour cancellation policy. You are responsible for the fee for all missed and canceled appointments. If you do not keep an appointment, you need to pay for each session that appointment and the next one at the very next appointment. It is CIP policy that all accounts be kept current at all times. You will not be charged for scheduled vacation time it with at least two weeks notice. Fees are also charged for client/therapist telephone conversations at the rate of 20% normal fee per 10 minute increment. ($30 fee would be $6 for a 10 minute phone conversation; $12 for a 20 minute conversation, etc.) If your check is heldreturned for insufficient funds or other reason, unless we agree otherwisethere will be a $15.00 fee per check charged along with the fee for the session. I If this happens a second time, there is a $20.00 fee per check along with the fee for the session. The third time a check is returned CIP will not accept future checks. After that, you must pay with cash or checks. Other professional services payments will be agreed to at the time of the request. Receipts for therapy will be sent to you if requested. If you choose to turn the receipt over to an insurance company or a third party payer, I CANNOT CONTROL THE SECURITY OF YOUR RECORDS. Remember your receipt often contains a diagnosis. Also insurance companies often require your entire, otherwise protected filemoney order. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the legal option of using customary 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 I release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. Fees will be reevaluated every 3 to 6 months to see if there has been a change in your financial situation. Fees will be raised at least one time per year. In most collection 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 clear 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 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 your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. Before I can disclose this information, both you and I must receive a written notification from the insurer stating what they are requesting, why they are requesting it, how long it will be kept and what will be done with the information when they are finished with it. In such situations, I will make every effort to release only the only minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I release regarding 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 patient’s treatment is his/her namenational medical information databank. I will provide you with a copy of any report I submit, the general nature of services providedif you request it. By signing this Agreement, and the amount due. The laws and standards of my profession require you agree that I keep treatment recordscan provide requested information to your carrier. Pursuant to HIPPA, I keep a Protected Health Information (PHI) record which includes Once we have all of the information about your reasons for seeking treatmentinsurance coverage, we will discuss what we can expect to accomplish with the way benefits that are available and what will happen if they run out before you feel ready to end your presenting problem impacts your life, your diagnosis, the goals we set for treatment, your progress towards those goals, your medical and social history, treatment history, and your billing/insurance recordssessions. As it states in the Confidentiality Section of this form, I will not release your PHI without your written permission unless in falls into the legal exceptions. PLEASE READ THE CONFIDENTIALITY SECTION OF THIS FORM VERY CAREFULLY. You It is important to remember that you always have the right to obtain your PHI as well as provide me with a written request pay for my services yourself to amend your PHI. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in my presence so that we can discuss avoid the contents. I am sometimes willing to conduct a review meeting without charge. I also will be happy to send your records to a mental health professional of your choice after you have signed a written release form. Patients will be charged an appropriate fee for any time spent in preparing information requests. If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, problems described above unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for your parents, and we will discuss it before I send it to themprohibited by contract.

Billing and Payments. You I accept credit cards, debit cards, HSA cards, and FSA cards. No checks or cash are accepted. Before scheduling your first session, information for an active credit, debit, HSA, or FSA card is required and will be expected truncated and securely stored by a third-party bankcard processor, Pineapple Payments/CardConnect, to pay meet Payment Card Industry (PCI) requirements. Please be advised that your card for each session at will be charged after the time it is held, session has been held unless we agree otherwise. I accept cash or checks. Other Payment schedules for other professional services payments will be agreed to at the time of the request. Receipts for therapy will be sent to you if when such services are requested. Any charges will show up on your financial statement (e.g., credit card statement) as “DC Services”. If you choose to turn the receipt over to an insurance company or payment after a third party payersession is not received for any reason, I CANNOT CONTROL THE SECURITY OF YOUR RECORDSwill notify you of this and further sessions will not be scheduled until the balance is paid in full. Remember If your receipt often contains a diagnosis. Also insurance companies often credit, debit, HSA, or FSA card on file has expired, I require you to replace it with an active card before your entire, otherwise protected filenext session is scheduled. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the legal option of using customary legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessarythis should occur, its costs costs, including court costs, reasonable attorney fees, and prejudgment interest on unpaid fees, will be included in the claim. In most collection situations, the only information I will release regarding a patient’s treatment is his/her name, the general dates, times, and nature of services provided, and the amount due. The laws and standards of my profession require that I keep treatment records. Pursuant to HIPPA, I keep a Protected Health Information (PHI) record which includes information about your reasons Your scheduled time is reserved for seeking treatment, the way your presenting problem impacts your life, your diagnosis, the goals we set for treatment, your progress towards those goals, your medical and social history, treatment history, and your billing/insurance records. As it states in the Confidentiality Section of this form, I will not release your PHI without your written permission unless in falls into the legal exceptions. PLEASE READ THE CONFIDENTIALITY SECTION OF THIS FORM VERY CAREFULLY. You have the right to obtain your PHI as well as provide me with a written request to amend your PHI. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in my presence so that we can discuss the contents. I am sometimes willing to conduct a review meeting without charge. I also will be happy to send your records to a mental health professional of your choice after you have signed a written release form. Patients will be charged an appropriate fee for any time spent in preparing information requestsyou. If you arrive late, your session will be shortened by that amount of time and you are under eighteen years still responsible for paying the full session fee. Please try to arrive punctually to get the full benefit of age, please your session. I might offer telehealth sessions which are sessions conducted by telephone or video. This would be charged at the regular rate. Please be aware that the law procedure code for telehealth services are different than for an in-office appointment and insurance coverage may provide not be available depending on your parents the right to examine your treatment recordsparticular plan. It is my policy your responsibility to request an agreement from parents that they agree to give up access to clarify this in advance with your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for your parents, and we will discuss it before I send it to theminsurance carrier.