Common use of Appointments and Cancellations Clause in Contracts

Appointments and Cancellations. During the initial consultation, your therapist will attempt to gain a general understanding of your situa- tion and determine the most appropriate treatment. We believe it is important for clients to take an ac- tive part in their treatment, so don’t hesitate to ask questions. Psychotherapy has been shown to have many benefits - better relationships, solutions to specific problems, feeling less distressed. While it is likely that you will make progress, there are no guarantees. If you cancel an appointment, you must notify us at least 24 hours before the scheduled time, or you will be billed the full session rate, not your copay. Insurance will not cover charges for unkept/late cancelled appointments, so you will personally be responsible for such charges. However, there will be no charge if you call at least 24 hours before the appointment time to cancel. There may be valid reasons such as illness, for cancelling without charge. If you have a contagious illness, do not come to the office. Call to cancel, even without 24 hours notice. You will not be charged. FEES AND HEALTH INSURANCE Most health plans cover part of our fee. There are two kinds costs you may incur that are not covered by your insurance company - deductibles and co-pays. Please pay any non-insured portion of the fee before each visit. Horizons contracts with insurance companies to cover our services at rates lower than our standard fees (see below). In such cases, your account balance will be adjusted when we receive insurance payment. However, if the insurance pays less than 100% of the contracted fee, you will owe any bal- ance up to 100% of that contracted fee. Deductibles and co-pays determined by your insurance com- pany may change during the course of your treatment. Sometimes health insurance companies will authorize more sessions than your insurance benefits will pay for. If you see your therapist for visits that are authorized but not paid for by your insurance bene- fits, by signing this form you agree to pay Horizons’ fee, as listed below, for each authorized visit that is not covered by your insurance plan. These are our fees for the following procedures (listed with the code numbers that may appear on the explanation of benefits statement from your insurance carrier): 90791- Diagnostic Evaluation - $200 90834- Individual psychotherapy 45 minutes (38-52 minutes) – $170 90837- Individual psychotherapy 60 minutes (53 minutes and above) – $185 90846/90847- Family psychotherapy, client not present/client present - $185 Although health insurance may aid in payment, you alone are responsible for paying for services. Your therapist will answer any questions about payment arrangements. For routine problems involving pay- ments and insurance, please call our office staff Monday through Thursday, 9 AM to 5 PM or Friday 9 AM to 12 Noon. All accounts are payable in full within 30 days after billing. Overdue accounts may be charged at 10% per year interest. If an account is overdue, regular payments are not being made, and no provision for payment has been made, we may turn the account over to a collection agency or attorney, as authorized by state or federal law. We reserve the right to collect any unpaid balance due. Clients will be notified in writing before Horizons takes such action to collect. Revised April 2019 _____STANDARD PAYMENT ARRANGEMENT: Payment for any deductible or noninsured portion of your fee is due before each session. This applies unless you initial “Alternative Payment Arrangement” on the next line. _____ALTERNATIVE PAYMENT ARRANGEMENT: Initial this line AND discuss with your therapist.

Appointments and Cancellations. During You are responsible for attending each appointment and agree to adhere to the initial consultationfollowing policy: If you cannot keep the scheduled appointment, you MUST notify our office to cancel or reschedule the appointment prior to 24 hours of the scheduled appointment time. Should you cancel or miss an appointment with notification less than 24 hours prior to your therapist appointment time this will attempt to gain a general understanding of result in being charged the full fee for your situa- tion and determine the most appropriate treatment. We believe it is important for clients to take an ac- tive part in their treatment, so don’t hesitate to ask questions. Psychotherapy has been shown to have many benefits - better relationships, solutions to specific problems, feeling less distressed. While it is likely that you will make progress, there are no guaranteesmissed appointment. If you cancel an appointmentor reschedule more than two times, we may re-evaluate your needs, desires, and motivations for treatment at this time. Should a client express and wish and/or desire to continue, a client may be asked to pre-pay for sessions when they are scheduled. If the client cancels or misses the session with less than 24 hour notice and the session is pre-paid, this follows the cancelation guidelines and the payment will not be reimbursed for the missed or canceled session less than 24 hours. Cancellations must be communicated by phone or in your Client Portal, NOT email or text. Phone/video sessions should be treated as regular in office sessions. If you must notify us are late getting on the phone, are unable to talk at least 24 hours before the our scheduled time, your battery has died and you are unable to access another confidential place to talk, or any other variable that would have you not be able to attend our session please know that you will be billed charged the full session rate, not your copay. Insurance will not cover charges fee for unkept/late cancelled appointments, so you will personally be responsible for such charges. However, there will be no charge if you call at least 24 hours before the appointment time to cancel. There may be valid reasons such as illness, for cancelling without chargesession. If you have are not present within the first 10minutes of your appointment time, it will be considered a contagious illnesscancelled or missed appointment which will result in you being charged the full fee for the missed appointment. If you are determined to be driving or in a compromising position that will impact your safety during your telehealth appointment time, do not come to the office. Call to cancel, even without 24 hours noticetherapist will cancel the session. You will not be charged. FEES AND HEALTH INSURANCE Most health plans cover part of our fee. There are two kinds costs you may incur that are not covered by your insurance company - deductibles and co-payscharged the full fee for the cancelled appointment. Please pay any nonmake the necessary arrangements you need to be available and present for your session. Psychotherapy is a uniquely personal service; therefore, consultations may be briefly interrupted. I may periodically take time off for vacation, seminars, and/or become ill. Attempts will be made to give adequate notice of these events. If I am unable to contact you directly, a colleague may contact you to cancel or reschedule an appointment. FEES: The fee for the initial/first therapeutic session is $150 and each therapy session thereafter is $125. Payment is due at the time of service. Acceptable forms of payment are: exact-insured portion amount cash, check (insufficient-funds checks will be returned upon full payment of the fee before each visit. Horizons contracts with insurance companies to cover our services at rates lower than our standard fees (see beloworiginal amount plus $30 for any returned check), or credit/debit card. In such casesthe event that a scheduled appointment time is missed or cancelled less than 24 hours in advance, please refer to the “Appointments and Cancellations” policy above. Payment is required at the start of your account balance session unless we agree otherwise before your appointment. At the start of each session, the therapist will charge your card on file and send you a copy of the paid invoice to your email on record. The clinician charges the hourly rate in quarter hours for phone calls over 10 minutes in length, email correspondence, reading assessments or evaluations, writing assessments or letters, and collaborating with necessary professionals (with your permission) for continuity of care. All costs for services outside of session will be adjusted when we receive insurance payment. However, if the insurance pays less than 100% of the contracted fee, you will owe any bal- ance up to 100% of that contracted fee. Deductibles and co-pays determined by your insurance com- pany may change during the course of your treatment. Sometimes health insurance companies will authorize more sessions than your insurance benefits will pay for. If you see your therapist for visits that are authorized but not paid for by your insurance bene- fits, by signing this form you agree to pay Horizons’ fee, as listed below, for each authorized visit that is not covered by your insurance plan. These are our fees for the following procedures (listed with the code numbers that may appear on the explanation of benefits statement from your insurance carrier): 90791- Diagnostic Evaluation - $200 90834- Individual psychotherapy 45 minutes (38-52 minutes) – $170 90837- Individual psychotherapy 60 minutes (53 minutes and above) – $185 90846/90847- Family psychotherapy, client not present/client present - $185 Although health insurance may aid in payment, you alone are responsible for paying for services. Your therapist will answer any questions about payment arrangements. For routine problems involving pay- ments and insurance, please call our office staff Monday through Thursday, 9 AM to 5 PM or Friday 9 AM to 12 Noon. All accounts are payable in full within 30 days after billing. Overdue accounts may be charged at 10% per year interest. If an account is overdue, regular payments are not being made, and no provision for payment has been made, we may turn the account over to a collection agency or attorney, as authorized by state or federal law. We reserve the right to collect any unpaid balance due. Clients will be notified in writing before Horizons takes such action to collect. Revised April 2019 _____STANDARD PAYMENT ARRANGEMENT: Payment for any deductible or noninsured portion of your fee is due before each session. This applies unless you initial “Alternative Payment Arrangement” on the next line. _____ALTERNATIVE PAYMENT ARRANGEMENT: Initial this line AND discuss with your therapistbilled.

Appointments and Cancellations. During the initial consultation, your therapist will attempt to gain a general understanding of your situa- tion situation and determine the most appropriate treatment. We believe it is important for clients to take an ac- tive active part in their treatment, so don’t hesitate to ask questions. Psychotherapy has been shown to have many benefits - better relationships, solutions to specific problems, feeling less distressed. While it is likely that you will make progress, there are no guarantees. If you cancel an appointment, you must notify us at least 24 hours before the scheduled time, or you will be billed the full session rate, not your copay. Insurance will not cover charges for unkept/late cancelled appointments, so you will personally be responsible for such charges. However, there will be no charge if you call at least 24 hours before the appointment time to cancel. There may be valid reasons such as illness, for cancelling without charge. If you have a contagious illness, please call to cancel even without 24 hours notice - do not come to the office. Call to cancel, even without 24 hours notice. You will not be charged. FEES AND HEALTH INSURANCE Most health plans cover part of our fee. There are two kinds costs you may incur that are not covered by your insurance company - deductibles and co-pays. Please pay any non-insured portion of the fee before each visit. Horizons All fees are due upon the completion of the service on the scheduled day. Neuro Wellness PC contracts with insurance companies to cover our services at rates a rate lower than our standard fees fee (see below). In such cases, your account balance will be adjusted when we receive insurance payment. However, if the insurance pays less than 100% of the contracted fee, you will owe any bal- ance balance up to 100% of that contracted fee. Deductibles and co-pays determined by your insurance com- pany company may change during the course of your treatment. Sometimes health insurance companies will authorize more sessions than your insurance benefits will pay for. If you see your therapist for visits that are authorized but not paid for by your insurance bene- fitsbenefits, by signing this form you agree to pay HorizonsNeuro Wellness PC’ fee, as listed belowabove, for each authorized visit that is not covered by your insurance plan. These are our fees for the following procedures (listed with the code numbers that may appear on the explanation of benefits statement from your insurance carrier): 90791- Diagnostic Evaluation - $200 185 90832- Individual psychotherapy 30 minutes (16-37 minutes) – $85 90834- Individual psychotherapy 45 minutes (38-52 minutes) – $170 140 90837- Individual psychotherapy 60 minutes (53 minutes and above) – $185 175 (The billing code for 90 minute sessions has been eliminated) 90846/90847- Family psychotherapy, client not present/client present - $185 160 Although health insurance may aid in payment, you alone are responsible for paying for services. Your therapist will answer any questions about payment arrangements. For routine problems involving pay- ments payments and insurance, please call our office staff Monday through Thursday, 9 AM to 5 PM or Friday 9 AM to 12 Noon. All accounts are payable in full within 30 days after billing. Overdue accounts may be charged at 10% per year interest. If an account is overdue, regular payments are not being made, and no provision for payment has been made, we may turn the account over to a collection agency or attorney, as authorized by state or federal law. We reserve the right to collect any unpaid balance due. Clients will be notified in writing before Horizons Neuro Wellness PC takes such action to collect. Revised April 2019 _____STANDARD PAYMENT ARRANGEMENT: Payment for any deductible or noninsured portion of your fee is due before each session. This applies unless you initial “Alternative Payment Arrangement” on the next line. _____ALTERNATIVE PAYMENT ARRANGEMENT: Initial this line AND discuss with your therapist.