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. 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. 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. _____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 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. 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. 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. _____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.