Common use of Billing and Payments Clause in Contracts

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs and time, even if I am called to testify by another party. Due to the nature of legal involvement, my rate for participation in legal activities is $500 per hour. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance 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. 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance

Billing and Payments. Your The client assumes 100% responsibility for all services, including any and all balances from pre- approved insurance coverage. I understand that the fee for this (these) service(s) will be $225 for the initial clinical interview and $175 per hour for subsequent scheduled therapy appointments. Full testing is charged at $165 per hour, which includes time administering, scoring, record reviewing and report writing. NOTE: Our private school entrance exam fee (for a WPPSI-IV or WISC-IV only) is $275. Payment is due at time of services. The rate of insurance reimbursement varies according to individual insurance contracts and I understand that I will be reimbursed based on my own health plan benefits and that I can request a “superbill” (a more detailed invoice) from Premier so that I may submit bills to my insurance company for said benefits. Though my health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with repay me for additional information regarding payment arrangements. Each client is some of these fees, I understand that I am fully responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation these services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs and time, even if I am called to testify by another party. Due to the nature of legal involvement, my rate for participation in legal activities is $500 per hour. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance 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. 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 aware that missed appointments may be subject to provide a clinical diagnosis. Sometimes I am required charge equal to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part fee of the insurance company files and will probably be stored in a computertherapy appointment. Though all insurance companies claim For Traditional Medicaid/Xxxxxx Care Clients: I understand that my benefits may allow up to keep such information confidential8 units of testing, per calendar year. If they are exhausted at the time of service because I have already had my child evaluated elsewhere within the calendar year, testing is no control over what they do with it once it is in their handslonger considered a covered Medicaid benefit and I may be responsible for payment of these services. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only Your signature below indicates that you provide writtenhave read the information in the Informed Consent to Treatment and agree to abide by its terms during our professional relationship. Client’s Printed Name Client’s Date of Birth Signature of client (or parent/guardian if client is a minor) Date *Email address you authorize PPS to use for correspondence (please print neatly) I, advancethe psychologist or clinician, have discussed the issues above with the client or with the minor client's parent or guardian. My observations of this person's behavior and responses give me no reason, in my professional judgment, to believe that this person is not fully competent to give informed and willing consent of said client or of the minor client's treatment. Signature of Psychologist or Clinician Date

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless agreed to otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, Vista Psychological & Counseling Centre, LLC, has the option of my professional timeusing legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require the clinician to disclose otherwise confidential information. In most collection situations, including preparation and transportation costs and timethe only information that the clinician will release regarding a client’s treatment is his/her name, even if I am called to testify by another party. Due to the nature of legal involvementservices provided, my rate for participation in legal activities is $500 per hourdates of service, and the amount due. INSURANCE REIMBURSEMENT REIMBURSEMENT: In order for us Vista Psychological & Counseling Centre, LLC, to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I Vista Psychological & Counseling Centre, LLC, will fill out forms and provide you with whatever reasonable assistance I we can in helping you receive the benefits to which you are entitled; however. However, you (not your insurance company) are responsible for full payment of my the clinician’s fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and Vista Psychological & Counseling Centre, LLC, will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, Vista will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require 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 psychotherapy/counseling after a certain number of sessions. While much can be accomplished in short term psychotherapy/counseling, some clients feel that they need more service after insurance benefits end. Some managed‐care plans will not allow the clinician to provide services to you once your benefits end. If this is the case, the clinician will do their best of find another provider who will help you continue your psychotherapy/counseling. You should also be aware that your contract with your health insurance company requires that I the clinician provide it with information relevant to the services that I provide provided to you. I am The clinician is required to provide a clinical diagnosis. Sometimes I am the clinician is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Recordclinical record. In such situations, I the clinician will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have the clinician has no control over what they do with it once it is in their hands. I In some cases, they may share the information with a national medical information databank. The clinician will provide you with a copy of any report I they submit, if you request it. By signing this Agreement, you agree that I the clinician can provide requested information to your insurance carrier. LIMITS ON CONFIDENTIALITY The law protects Once Vista Psychological & Counseling Centre, LLC, has all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, it will be possible to others discuss what can be accomplished with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide written, advancealways have the right to pay for the clinician’s services to avoid the potential problems described above. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS. YOUR SIGNATURE ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPPA NOTICE FORM DESCRIBED ABOVE. Client or Guardian Signature Date Relationship to Client

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise or unless you have insurance coverage, which requires another arrangement. Please see our fee schedule, below. Fee Schedule: Initial appointment : $210 Individual, couples or family session $180.00 Telephone sessions (per 15 minute increments) $60.00 Correspondence (per 15 minute increments) $60.00 Psychological evaluations and testing (per hour) $200.00 Forensic work and court appearances (per hour) $300.00 Returned Check Fee $25.00 It is often necessary when seeing children in psychotherapy for the clinician to spend time outside of my professional the session working on the case. Insurance typically only covers face to face therapy and therefore such outside of the session time is billed directly to parents. I will notify you when these circumstances arise. Additional fees will be billed for the following types of situations: communicating with your child's guidance counseler or teacher, reading previous evaluations or reports, revising 504 plans or IEPs, attending school meetings, scoring assessment measures or other diagnostic evaluations. Fee is $6 0 for 15 minute increments of time. If your account is more than 60 days in arrears and suitable arrangements for payment have not been agreed to, I have the option of using legal means to secure payment, including preparation and transportation collection agencies or small claims court. If such legal action is necessary, the costs and timeof bringing that proceeding will be included in the claim. In most cases, even if the only information, which I am called would release to testify by another party. Due to a court or collection agency, would be the client’s name, the nature of legal involvement, my rate for participation in legal activities is $500 per hourthe services provided and the amount due. INSURANCE REIMBURSEMENT Insurance Reimbursement In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have are available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will provide you with whatever reasonable assistance I can in helping you receive facilitating your receipt of the benefits to which you are entitled; however, you (including filling out forms as appropriate. However, you, and not your insurance company) , are responsible for full payment of my feesthe fee. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limitTherefore, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance coveragequestions, you should call your plan administratoradministrator and inquire. Of course, I will provide you with whatever information I can based on my experience and will be happy to help try to assist you in understanding deciphering the information you receive from your insurance companycarrier. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant If necessary to the services that I provide to you. resolve confusion, I am required willing to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of call the carrier on your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advancebehalf.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. Returned checks are subject to a $35 fee. If your account has not been paid for more than 90 days, and suitable arrangements for payment have not been agreed upon, we have the option of my professional timesuspending or discontinuing treatment, including preparation and transportation costs and timeand/or using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court, even if I am called which will require us to testify by another partydisclose otherwise confidential information. Due to In most collection situations, the only information we release regarding a patient’s treatment is his/her name, dates, the nature of services provided, and the amount due. If such legal involvementaction is necessary, my rate for participation its costs will be included in legal activities is $500 per hourthe claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I Warner & Associates, LLC does not participate with any insurance companies. We will provide you with whatever reasonable assistance I can in helping you receive the benefits an invoice to which you are entitled; however, you (not submit to your insurance company) are responsible company or flexible spending account for full payment of my fees. This includesreimbursement, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by according to your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquireindividual health insurance plan benefits. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I we will provide you with whatever information I we can based on my experience our experience, and will be happy to attempt to help you in understanding the information you receive from required by your insurance companycompany for reimbursement. You should also be aware that your contract with your health insurance company requires YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA FORM DESCRIBED ABOVE. Client Name Client Signature (if 18 or over) Parent/Guardian Name (if applicable) Date Parent/Guardian Signature (if applicable) Warner & Associates, LLC Staff Name Date Warner & Associates, LLC Staff Signature Consent to Treatment I acknowledge that I provide it with have received, have read, and understand the “General Information and Psychological Services Agreement.” I have had my questions answered adequately at this time. I understand that I have the right to ask questions throughout the course of my assessment and/or treatment and may request an outside consultation. I also understand that the mental health provider may offer additional information relevant about specific treatment issues and treatment methods on an as- needed basis during the course of my treatment or evaluation, and that I have the right to consent to or refuse such treatment. I understand that I can expect regular review of treatment to determine whether treatment goals are being met. I agree to be actively involved in the treatment, and in the review process. No promises have been made as to the services results of this treatment or evaluation, or of any procedures utilized within it. I further understand that I provide may stop my treatment or evaluation at any time, but agree to youdiscuss this decision first with my mental health provider. My only obligation, should I decide to stop treatment, is to pay for the services I have already received, and to attend one final session to discuss my reasons and to terminate. I have been informed that I must give 24 hours notice to cancel an appointment, and that I will be charged $80.00 if I do not cancel or show up for a scheduled session. I am 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree aware that I can provide requested information must authorize the mental health provider in writing to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment my treatment, but that confidentiality can be broken under certain circumstances of danger to others myself or others. I understand that once I release information to insurance companies or any other third party, there is no guarantee that it will remain confidential. My signature signifies my understanding and agreement with these issues, and with the additional information conveyed in this statement. Client Name Date Client Signature (if you sign a written Authorization form 18 or over) Patient/Guardian Name (if applicable) Date Patient/Guardian Signature (if applicable) Warner & Associates, LLC Staff Name Date Warner & Associates, LLC Signature Confidential Background Information Client Name: M / F Age: Date of Birth: / / Address: City/State: Zip: Phone: Preferred Email address: Preferred method of contact: Your acknowledgements: I certify that meets certain legal requirements imposed by HIPAAthe information provided above is complete and accurate. There I agree to notify Warner & Associates, LLC if there are other situations that require only that you provide written, advanceany changes in the above information. Client Name: Client Signature: Date: MARYLAND NOTICE FORM Notice of Policies and Practices to Protect the Privacy of Patient Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. You will be asked to pay at the end of my professional timeeach session. You may pay in cash, including preparation check, or credit card. You will be given a receipt that provides information an insurer would need if you decide to ask for some type of reimbursement from your carrier. If your account has not been paid for more than 60 days and transportation costs and timearrangements for payment have not been agreed upon, even if I am called have the option of using legal means to testify by another partysecure the payment. Due This may involve hiring a collection agency or going through small claims court which will require 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 nature of services provided, and the amount due. If such legal involvementaction is necessary, my rate for participation its costs will be included in legal activities is $500 per hourthe claim. By signing this agreement, you authorize me to employ the services of an outside collection agent or attorney to seek payment of all unpaid fees. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your Also, please note that I am not on any insurance company prior to our first meeting so panels. I will provide you with a receipt at time of payment that you may fully understand use to request reimbursement from your benefits as they pertain to our work togetherinsurance carrier. You should carefully read the section in your insurance coverage booklet that describes mental health services. If at any point you have questions about your insurance 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 patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that 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 Recordclinical record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects By signing this agreement, you authorize me to provide your health insurance company with all information requested of me pertaining to the privacy services I provide to you or your family member. Once we have all of all communications between a client and a psychologist. In most situations, I can only release the information about your treatment insurance coverage, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide writtenalways have the right to pay for my services yourself to avoid the problems described above. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ABIDE BY ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP. IN ADDITION, advanceYOUR SIGNATURE ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. Parent Date Parent Date Xxxxxx Xxxxx Xxxxxxxx, Ph.D. Date Dallas Wellness Group, PLLC

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of my professional timeusing legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, including preparation and transportation costs and timethe only information we release regarding a patient’s treatment is his/her name, even if I am called to testify by another party. Due to the nature of legal involvementservices provided, my rate for participation in legal activities is $500 per hourand the amount due. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I We will fill out forms and provide you with whatever reasonable assistance I we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my our fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes outpatient mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I Our staff will provide you with whatever the information I can based on my experience we receive when we verify your coverage and will be happy to help you in understanding understand the information you receive from benefits we are told by your insurance company. Please be aware that verification is not a guarantee of payment. 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 patients feel that they need more services after insurance benefits end. In this case your therapist will discuss payment options with you for future sessions. You should also be aware that your contract with your health insurance company requires that I we provide it with information relevant to the services that I we provide to you. I am In these situations your therapist is required to provide a clinical diagnosis. Sometimes I am we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I we have no control over what they do with it once it is in their hands. I will provide you In some cases, it is possible that they may share the information with a copy of any report I submit, if you request itnational medical information databank. By signing this Agreement, you agree that I your therapist can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance.

Billing and Payments. Your health insurance I accept cash and checks only. You will be expected to pay prior to each session, unless we agree otherwise. In circumstances of unusual financial hardship, I may cover all or part be willing to negotiate a payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. HoweverThis may involve hiring a collection agency or going through small claims court 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. SESSIONS AND PROFESSIONAL FEES If therapy services are ultimately responsible begun, I typically schedule one 45-50-minute session (one appointment hour for all fees incurred45-50 minutes duration) per week, although some sessions may be longer or more or less frequent. An intake session may last 1 ½ hours. Your appointment time is reserved for you. You should contact your health insurance company or consult will be expected to pay for it unless you provide 24 hours advance notice of cancellation. My fee for therapy is $90 per 45-50 minute hour to be paid prior to the session. The fee for initial intake session is $120.00. If there are special circumstances you would like for me to consider regarding these fees, you must discuss the circumstance with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each prior to the first session. - 50-55 minute individual If you miss an appointment without notice or couples counseling session: $290* - Late Cancel (within 48 fail to call more than 24 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there in advance, you will be $35 service fee for insufficient funds or payments that are not made according to our payment agreementbilled forthat time. This $35 fee is in In addition to the original payment due to me. weekly appointments, I also charge $290 per hour this amount for other professional services you may need, though I will break down the hourly cost if I we work for periods of less than one hour. Other services include classroom observations, report writing, telephone conversations lasting longer than 5 15 minutes, consultation servicesconsulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of meme . If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs and time, even if I am called to testify by another partycosts. Due to the nature difficulty of legal involvement, my rate I charge $300 per hour for participation in preparation and attendance at any legal activities is $500 per hourproceeding. INSURANCE REIMBURSEMENT In order Signature Page Your signature on this document indicates that you understand and agree to the information provided for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for the duration of your treatment. If you have a health insurance policyare seeking child or family therapy, it will usually provide some coverage your signature also gives permission for mental health treatmentyou minor children to receive therapy services. I will provide you with whatever reasonable 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 have read and understood all of my fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance 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. 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 youin this agreement. 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files have asked any questions and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request itreceived answers needed. By signing singing this Agreement, you document I agree that I can provide requested information to your carrierall conditions herein and also hereby give permission for my/our minor children to receive therapy services. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advanceAdult Signatures Below: _Date (Printed name) _Date

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290300* - Late Cancel (within 48 hours for any reason) or No Show: $290300* - 90-minute group therapy session: $8090* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there You will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is notified of this adjustment in addition to the original payment due to meadvance. I also charge $290 300 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs and time, even if I am called to testify by another party. Due to the nature of legal involvement, my rate for participation in legal activities is $500 per hour. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance 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. 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advanceadvance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If a client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning the professional services that I provided you, such information is protected by the psychologist-client privilege law. I cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. There are some situations in which I am legally obligated to take actions that I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. • If I have reasonable cause to believe that any child or dependent adult with whom you may have contact or knowledge of has been abused, I am required to file a report with the appropriate government agency. Once such a report is filed, I may be required to provide additional information. • if you threatened violence, I must protect the other person(s) and you by possibly disclosing information about your threat to the appropriate persons and authorities • if you become mentally ill and become unable to take care of your basic needs or become a danger to yourself or others and also refuse treatment, I must report your condition to the authorities • if you provide me with information that another health care provider is not able to practice with reasonable skill and safety due to a mental or physical condition • If a client communicates an imminent threat of serious physical harm to him/ herself, I may be required to disclose information in order to take protective actions. These actions may include initiating hospitalization or contacting family members or others who can assist in providing protection. • if you tell me that you are suffering from an infectious disease, such as HIV, I must report your identity to the local health care officer. • under certain select circumstances the court may order your treatment records be released to another party involved in litigation with you If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. ONLINE VIDEO MEETINGS While my preference is to meet in person, I have discovered that meaningful therapy can indeed take place over video conference. It may be that either of us would prefer to, or need to, meet via video rather than in person, whether due to travel by either you or myself, or for other reasons. In the event that you should prefer to meet over video conference, either on an ongoing or temporary basis, please simply let me know before our session time. I too reserve the right the meet via video should my own schedule necessitate. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to me confidentially by others, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. If I refuse your request for access to your records, you have a right to of review, which I will discuss with you upon request. PATIENT RIGHTS HIPAA provides you with several rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Clients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. Even where parental consent is given, children over age 12 may have the right to control access to their treatment records. While privacy in psychotherapy is very important, particularly with teenagers, parental involvement is also essential to successful treatment, particularly with younger children. For children age 12 and over, I request an agreement between my client and his/her parents allowing me to share general information about the progress of the child’s treatment and his/her attendance at scheduled sessions. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. Statement of Agreement Regarding Fees and Services - Consent: Your signature below indicates that you have read the Notice of Privacy Practices and the information included in this document and agree to abide by this document’s stipulations during our professional relationship. I have read Xx. Xxxxxxxx'x policies and my responsibilities as a client, fee for service, confidentiality, and patient rights. I understand and agree that I will be charged: for any outstanding, unpaid bills; a full session fee for any appointments that I miss for any reason with less than 48 hours notice; and, if I am a member of a couple, for any sessions missed by one or both members of the couple. I have had the opportunity to ask questions and discuss them, and give my informed consent for services. If requested, I have received a copy of this agreement. I agree to abide by the terms therein. Client Name (Printed) Client Signature Date Guardian Name (Printed) (if applicable) Date

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your insurer determines that they will not pay for services, you are ultimately responsible to pay for services. Payment that is not made at the time of my professional time, including preparation and transportation costs and time, even if a session is expected within 30 days. I am called happy to testify by another partywork with patients to arrange for payment plans if that becomes necessary. Due If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using a legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action becomes necessary, the costs will be included in the claim. In most collection situations, the only information I release regarding treatment is the client’s name, the nature of legal involvementthe services provided (i.e. individual psychotherapy), my rate for participation in legal activities is $500 per hourand the amount due. Initials (of Individual, couple or family) 3 INSURANCE REIMBURSEMENT REIMBURSEMENT: In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clarify benefit, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require pre- authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel they need more services after insurance benefits end. (Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that your contract with your health most insurance company requires that I provide it with information relevant companies require you to the services that I provide to you. I am required authorize me to provide them with a clinical diagnosis. Sometimes I am required to provide relate additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requestedrecord (in rare cases). This information will become part of the insurance company company’s files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects Once we have all the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your treatment. There are other situations that require only It is important to remember that you provide written, advancealways have the right to pay for my services yourself to avoid these problems that compromise your full confidentiality.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise or unless you have insurance coverage which requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of my professional timeusing legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. In most collection situations, including preparation and transportation costs and timethe only information I release regarding a patient’s treatment is his/her name, even if I am called to testify by another party. Due to the nature of legal involvementservices provided, my rate for participation in legal activities is $500 per hourand the amount due. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, course I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to 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 a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. You should also be aware that your contract with your health most insurance company requires that I provide it with information relevant companies require you to the services that I provide to you. I am required authorize me to provide them with a clinical diagnosis. Sometimes I am required have to provide additional clinical information such as treatment plans or summaries, or copies of your the entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requestedrecord (in rare cases). 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 have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects Once we have all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end our sessions. There are other situations that require only It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. CONTACTING ME I am often not immediately available by telephone. While I am usually in my office between 8 AM and 5 PM, I probably will not answer the phone when I am with a patient. I do check my phone regularly in between sessions when possible. I will make every effort to return your call within 24 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you can’t wait for me to return your call, please go to your nearest emergency room or call 911 or the San Diego County Access Crisis line, (000) 000-0000. If I will be unavailable for an extended time, I will provide writtenyou with the name of a colleague to contact, advanceif necessary. As I am sure you are aware, I am required to keep records of the professional services I provide for your treatment, or our work together. Because these records contain information that can be misunderstood by someone who is not a mental health professional, it is my general policy that patients may not review them; however, I will provide at your request a treatment summary unless I believe that to do so would be emotionally damaging. If that is the case, I will be happy to send the summary to another mental health professional who is working with you. You should be aware that this will be treated in the same manner as any other professional (clinical) service and you will be billed accordingly. SOCIAL MEDIA POLICY This last section outlines my office policies related to use of Social Media, i.e., how I conduct myself on the Internet as a mental health professional and how you can expect me to respond to various interactions that may occur between us on the Internet. As new technology develops and the Internet changes, there may be times when I need to update these policies. If I do so, I will notify you in writing of any policy changes and make sure you have a copy of the updated policy. Friending I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship.

Billing and Payments. Your health If you have insurance may cover all coverage for my services, you will be expected to pay any co-pay, co-insurance or part deductible at the time of the fees service and I will work with you to facilitate the exchange of information with be billed by my billing service for any other balance not covered by your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of mecompany. If you become involved in legal proceedings that require are not using insurance to help pay for my participationservices, you will be expected to pay for all each session at the time it is held. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of my professional timeusing legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, including preparation and transportation costs and timethe only information I release regarding a patient’s treatment is his/her name, even if I am called to testify by another party. Due to the nature of services provided, and the amount due. If such legal involvementaction is necessary, my rate for participation its costs may be included in legal activities is $500 per hourthe claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I If you provide me with your insurance card/information, my billing service will provide you with whatever reasonable assistance I can in helping you receive the benefits to which you are entitledfile claims for you; however, you (not your insurance company) are responsible for full payment of my fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance 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 prior 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 patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to refer you to 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 clinical information relevant to the services that I provide to you. I am required to provide a clinical diagnosisdiagnosis and a description of the service provided on particular dates. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this AgreementIt is important to remember that you always have the right to pay for my services yourself to avoid the problems described above, unless prohibited by contract. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days during the week, I probably will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by voice mail that I monitor frequently on days I am in the office. I will make every effort to return your call on the same day you make it, as long as I am in the office. In the event of an emergency, emergency numbers will be listed on my voice mail message. In an emergency, you agree also may contact your family physician, go to an emergency room, or call your local emergency services such as -911 or the police. ELECTRONIC COMMUNICATIONS POLICY In order to maintain clarity regarding our use of electronic modes of communication during your treatment, I have prepared the following policies. This is because the use of various types of electronic communication is common in our society, and many individuals believe this is the preferred method of communication with others, whether their relationships are social or professional. Many of these common modes of communication, however, put your privacy at risk and can be inconsistent with the law and with the standards of my profession. Consequently, these policies have been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law. EMAIL AND TEXT COMMUNICATIONS I use email communications only for administrative purposes unless we have made another agreement. That means that emails should be limited to things like setting and changing appointments, billing matters, and other related issues. Please do not email me about clinical matters because it is not a secure way to contact me. If you need to discuss a clinical matter with me, please call me so we can discuss it on the phone or wait so we can discuss it during your therapy session. The telephone or face-to-face context simply is much more secure as a mode of communication. I use a landline telephone in the office and do not text. SOCIAL MEDIA I do not communicate with, or contact, any of my clients through social media platforms like Twitter and Facebook. In addition, if I discover that I have accidentally established an online relationship with you, I will cancel that relationship. This is because these types of casual social contacts can create significant security risks for you. If you have an online presence, there is the possibility that you will encounter me by accident. If that occurs, please discuss it with me during our time together. I believe that any communications with clients online have a high potential to compromise the professional relationship. In addition, please do not try to contact me this way. I will not respond and will terminate any online contact no matter how accidental. WEBSITES I have a website that you are free to access. I use it for professional reasons to provide requested information to others about me and my practice. You are welcome to access and review the information that I have on my website, and, if you have questions about it, we should discuss this during your carriertherapy sessions. WEB SEARCHES I will not use web searches to gather information about you without your permission, I believe that this violates your privacy rights; however, I understand that you may choose to gather information about me I this way. In this day and age there is an incredible amount of information available to individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can deal with it and its potential impact on your treatment. Recently it has become fashionable for clients to review their health care provider on various websites. Unfortunately, mental health professionals cannot respond to such comments and related errors because of confidentiality restrictions. If you encounter such reviews of me or any professional with whom you are working, please share it with me so we can discuss it and its potential impact on your therapy. Please do not rate my work with you while we are in treatment together on any of these websites. This is because it has a significant potential to damage our ability to work together. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization authorization form that meets certain legal requirements imposed by HIPAA and/or Indiana law. If an adult is being seen with another adult for marital/family therapy, I normally require the signed authorizations of both adults before releasing records. However, in the following situations, no authorization is required: • I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you do not object, I will not tell you about these consultations unless I feel that it is important to our work together. • I also have a contract with a billing service and with an electronic medical records company. As required by HIPAA, I have formal business associate contracts with these businesses, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with a blank copy of this contract. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If you are involved in a court proceeding and a request is made for information concerning the professional services I provided to you, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your or your parent’s/legal guardian’s written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • I may provide information to a coroner or medical examiner, in the performance of that individual’s duties. • If a patient files a complaint or lawsuit against me, I may disclose information regarding that patient in order to defend myself. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice. • If I have reason to believe that a child is a victim of child abuse or neglect, the law requires that I file a report with the appropriate government agency, usually the local child protection service. Once such a report is filed, I may be required to provide additional information. • If I have reason to believe that someone is an endangered adult, the law requires that I file a report with the appropriate government agency, usually the adult protective services unit. Once such a report is filed, I may be required to provide additional information. • If a patient communicates an actual threat of physical violence against an identifiable victim, or evidences conduct or makes statements indicating imminent danger that the patient will use physical violence or other situations means to cause serious personal injury to others, I may be required to disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. • If a patient communicates an imminent threat of serious physical harm to him/herself, I may be required to disclose information in order to take protective actions. These actions may include calling the police, initiating hospitalization, or contacting family members or others who can assist in providing protection. If such a situation arises, I will make appropriate efforts to discuss it with you before taking any action, and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that require only we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in unusual circumstances in which disclosure would physically endanger you and/or others, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of $10 for the first 10 pages, 50 cents per page for pages 11-50 and 25 cents per pages 51 and over (and to charge for certain other expenses). If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the privacy notice form for my practice, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is my policy to provide writtenparents only with general information about the progress of the child’s treatment and his/her attendance at scheduled sessions. The exception would be if the child agrees that I share further information, advanceif the parent is included in a family therapy session in which information is shared, or if I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. I will not do a custody evaluation. I also will not share information with the court in the event of a custody battle, except if the court orders me to do so, or if there is appropriate consent by the patient/parent/legal guardian(s). ADDITIONAL INDIANA LAW REQUIREMENT Indiana law also requires me to inform you that I may only provide those mental health services that I am qualified to provide within the scope of my license, certification, and training. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. Name of Patient

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless you and your therapist agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. You will be asked to pay at the end of my professional timeeach session. You may pay in cash, including preparation check, or credit cards. You will be given a monthly (unless otherwise requested) receipt that provides information an insurer would need if you decide to ask for some type of reimbursement from your carrier. Once an appointment is scheduled, payment is expected unless 24 hours advance notice of cancellation is provided. If a session is missed and transportation costs advance notice has not been provided, a $100 fee will be assessed. If your account has not been paid for more than 60 days and timearrangements for payment have not been agreed upon, even if I am called we have the option of using legal means to testify by another partysecure the payment. Due This may involve hiring a collection agency or going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a patient's treatment is his/her name, the nature of services provided, and the amount due. If such legal involvementaction is necessary, my rate for participation its costs will be included in legal activities is $500 per hourthe claim. By signing this agreement, you authorize us to employ the services of an outside collection agent or attorney to seek payment of all unpaid fees. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I We will fill out forms and provide you with whatever reasonable assistance I we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my your therapist’s fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You Also, please note that our therapists are strongly advised to contact your not on any insurance company prior to our first meeting so panels. Your therapist will provide you with a receipt at time of payment that you may fully understand use to request reimbursement from your benefits as they pertain to our work togetherinsurance carrier. You should carefully read the section in your insurance coverage booklet that describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I we will provide you with whatever information I we can based on my our experience and will be happy to help you in understanding the information you receive from your insurance company. Due to the rising costs of healthcare, 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 patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow us to provide services to you once your benefits end. If this is the case, we will do our 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 your therapist provide it with information relevant to the services that I he/she provide to you. I am Your therapist is required to provide a clinical diagnosis. Sometimes I am he/she is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Recordclinical record. In such situations, I your therapist will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have your therapist has no control over what they do with it once it is in their hands. I In some cases, they may share the information with a national medical information databank. Your therapist will provide you with a copy of any report I submithe/she submits, if you request it. By signing this Agreement, you agree that I your therapist can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects By signing this agreement, you authorize your therapist to provide your health insurance company with all information requested of them pertaining to the privacy services he/she provide to you or your family member. Once we have all of all communications between a client and a psychologist. In most situations, I can only release the information about your treatment insurance coverage, you and your therapist will discuss what you can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide writtenalways have the right to pay for your therapist’s services yourself to avoid the problems described above. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ABIDE BY ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP. IN ADDITION, advanceYOUR SIGNATURE ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. SIGNED Patient Date Xxxx Xxx, Ph.D. Date Texas License # 37071 or

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. 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 balance. It is understood that in the event your portion of the balance due becomes 90 days or more delinquent, a late fee of $15.00 per month will be charged until the amount you owe is paid in full. There will be a $15.00 charge on all returned checks. If your account has not been paid for more than 90 days and arrangements for payment have not been agreed upon, I have the option of my professional timeusing legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, including preparation and transportation costs and timethe only information I release regarding a patient’s treatment is his/her name, even if I am called to testify by another party. Due to the nature of services provided, and the amount due. [If such legal involvementaction is necessary, my rate its costs will be included in the claim.] Initial here: Insurance Coverage and Co-payments You are responsible for participation in legal activities is $500 per hour. INSURANCE REIMBURSEMENT In order obtaining prior authorization for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for from your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatmentcarrier. I will provide you with whatever reasonable assistance I can in helping you receive the benefits am willing to which you are entitledbill your insurance; however, you (not your insurance company) are responsible for full payment of my fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limitTherefore, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You Co-payment amounts are strongly advised 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 provided to you or you may contact your insurance company prior health plan for this information. For special modalities of treatment not covered by your benefits plan, a written agreement needs to our first meeting so be signed between you and this office/practitioner. This agreement should outline your understanding that it is not a covered benefit and will also cover the agreed fees and treatment plan you may fully understand your benefits as they pertain to our work togetherexpect. . If at At any point time during treatment should you have questions about your become ineligible for insurance coverage, call your plan administrator. Of course, I you will provide notify the practitioner and understand 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. 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part responsible for 100% of the insurance company files and will probably be stored in a computerbill. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advanceInitial here:

Billing and Payments. Your health insurance may cover all I accept credit cards, debit cards, HSA cards, and FSA cards. No checks or part of the fees cash are accepted. Before scheduling your first session, information for an active credit, debit, HSA, or FSA card is required and I will work with you be truncated and securely stored by a third-party bankcard processor, Pineapple Payments/CardConnect, to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel meet Payment Card Industry (within 48 hours for any reasonPCI) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreementrequirements. Please note there be advised that your card for each session will be $35 service fee for insufficient funds or payments that are not made according to our payment agreementcharged after the session has been held unless we agree otherwise. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour Payment schedules for other professional services you may needwill be agreed to when such services are requested. Any charges will show up on your financial statement (e.g., though credit card statement) as “DC Services”. If payment after a session is not received for any reason, I will break down notify you of this and further sessions will not be scheduled until the hourly cost if balance is paid in full. If your credit, debit, HSA, or FSA card on file has expired, I work require you to replace it with an active card before your next session is scheduled. If your account has not been paid for periods more than 60 days and arrangements for payment have not been agreed upon, I have the option of less than one hourusing legal means to secure the payment. Other This may involve hiring a collection agency or going through small claims court. If this should occur, its 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 dates, times, and nature of services include telephone conversations lasting longer than 5 minutes, consultation servicesprovided, and the amount due. APPOINTMENTS Your scheduled time spent performing any other service you may request of meis reserved for you. If you become involved arrive late, your session 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 elephone Sessions Depending on the circumstance, I 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 legal proceedings 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 me at least 24 hours before the start of the appointment time, or you no-showed (i.e., you did not come to your appointment and did not provide any notification that require my participationyou were not coming), you will be expected subject to pay the full fee of the initial evaluation ($395) for all any 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 my professional the appointment time. For existing patients, including preparation no-shows, cancellations, and transportation costs and time, even rescheduled sessions will be subject to a full charge of the session fee if I am called was not provided notification at least 24 hours before the start of the appointment time. It is your responsibility to testify ensure I have received your cancellation or rescheduling request which you may do by another partytelephone, email, or in-person communication. Due Inclement Weather I will provide you notification as soon as I can whether I will be able see patients in the office on inclement weather days. Even if I come to the nature office to see patients, if you no-show, cancel, or reschedule your appointment less than 24 hours of legal involvementthe 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 will be an option. COMMUNICATION AND INTERNET-RELATED ISSUES I am often not immediately available by telephone or email. Though I am usually in my rate for participation in legal activities is $500 per houroffice between 8am and 3pm Monday through Friday, I will not answer the telephone or check emails when I am with a patient. INSURANCE REIMBURSEMENT In order for us When I am unavailable, please leave me a voicemail or an email message; I monitor both frequently. I will make every effort to set realistic treatment goals return your message within 24 hours with the exception of weekends and priorities, it is important to evaluate what resources you have available to pay for your treatmentholidays. If you have are difficult to reach by telephone, please let me know of some times when you will be available. Please note that face-to-face sessions are highly preferable to telephone sessions. However, in the event that you are out of town, sick, or need additional support, telephone sessions may be available and will be subject to a health insurance policyfee as described under FEES. If you are unable to reach me and feel that you cannot wait for me to return your call, it contact your family physician, call 911, or go to the nearest emergency room. If I will usually provide some coverage be unavailable for mental health treatment. an extended time, I will provide you with whatever reasonable assistance the 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, 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 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 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 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 me an email address, I will 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 your sleep log. I 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 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 helping 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 the benefits from you and send to which you are entitled; however, you (not filed in your insurance company) are responsible for full payment patient chart and will thus become part of my fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurerlegal record. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limitpersonal contact information (e.g., telephone number, email address) changes, it is your responsibility to contact the insurer inform me of these changes as soon as possible so as not to inquiremiss appointment reminders, etc. It I am not responsible for charges associated with such changes. P atient Portal Your secure patient portal is very important xxxxx://xxxxxxxxxxxxxxx.xxxxxxxxxxxx.xx/. From here, you can log in to (1) view your appointments, (2) in some cases, request appointments, (3) review and complete documents I share with you, and (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 xxxxx://xxx.xxxxxxxxxxxxxx.xxx/privacy/. M y Website I have a website that you find out exactly what mental health services your insurance policy coversare free to access: xxx.xxxxxxxxxxxxxxx.xxx. I use it for professional reasons to provide information to others about me and my practice. You are strongly advised welcome to contact your insurance company prior to our first meeting so 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 fully understand encounter me by accident. Due to the importance of your benefits as they pertain to our work together. . If at any point you have questions about your insurance coverage, call your plan administrator. Of courseconfidentiality and the importance of minimizing dual relationships, I will provide you with whatever information I can based do not accept friend or contact requests or respond to any messages from current or former patients on my experience and will be happy to help you in understanding the information you receive from your insurance company. 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 summariesany social networking site (Facebook, or copies of your entire Clinical Record. In such situationsLinkedIn, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advanceetc.).

Billing and Payments. Your health You are responsible for coming to your session on time and at the time we have scheduled. If you are using insurance, your insurance may will not cover all or part the session if you are 15 minutes late. Therefore, you would be responsible for the session fee of $100. If you are late, we will end on time and not run over into the fees and I next person's session. Clients must provide the therapist a minimum of 24 hours notice in the event they will work miss a session. Sessions cancelled with less than 24 hours advanced notice will be charged $50 to the client. If you to facilitate the exchange of information with 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 paymentmissed sessions or late cancellation fees. However, 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 original scheduled appointment) on the charge incurred for a late cancellation/missed appointment. Repeated “no-show” appointments could result in referring you to another practitioner. All payments are ultimately responsible for all fees incurreddue 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. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service My fee for insufficient funds or payments that are not made according a session is $100.00. If we decide to our payment agreementmeet for a longer session, I will bill you prorated on the hourly fee. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour Payment schedules for other professional services you will be agreed to when they are requested. In circumstances of unusual financial hardship, I may needbe 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, though I will break down the hourly cost if I work for periods 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 less than one hourmaking alternative payment arrangements if this happens. Other services include telephone conversations lasting longer than 5 minutesIn the event of a missed appointment (late cancelation or no-show), consultation services, and your card will be charged at the time spent performing 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 other service you may request patient balances must be paid at the time of me. If you become involved in legal proceedings that require my participation, services or you will be expected required to pay for all reschedule your appointment when the balance has been paid. This may mean not being seen at the time of my professional time, including preparation and transportation costs and time, even your appointment if I am called to testify by another party. Due to the nature of legal involvement, my rate for participation in legal activities is $500 per hour. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available 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: Xxxxxxxxx Xxxxxxxx, LCSW, are acceptable. Please note: If you 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 pay for your treatmentbalance. If you your account has not been paid for more than 30 days and arrangements for payment have a health insurance policynot been agreed upon, it will usually provide some coverage for mental health treatmentI have the option of using legal means to secure the payment. 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, it’s costs will be included in the claim. 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. INSURANCE REIMBURSEMENT 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 clients elect to use their insurance to help pay for our time together. If you decide to involve your insurance company in your services, I will fill out forms and provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised But, before deciding to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about use your insurance coverage, call 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 plan administratorservices, or “treatment,” be certified as “medically necessary.” This requires your therapist provide the insurance company with a diagnosis to justify your treatment. Of courseIt 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 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 will provide may be required to send the insurance company much personal information about you in addition to the mental health diagnosis. I may also be required to write frequent reviews releasing more personal information with whatever each review. I cannot guarantee that this information I can based on my experience and will be happy 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 help you in understanding the information you receive from treat your diagnosis. As noted earlier, insurance companycompanies will not pay for missed appointments, whether no-shows or late cancellations. You should also be aware 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 your contract with your health insurance company requires that I provide it with information relevant to the services that I provide time still belongs 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreementthe “Acknowledgment of Notifications” form, you agree that I Xxxxxxxxx Xxxxxxxx, LCSW can provide requested information to your carrier, should you decide to involve your insurance company in your services. LIMITS ON CONFIDENTIALITY The law protects Remember, you have the privacy right to pay privately for your psychotherapy and leave this third party out of all communications your confidential relationship with your provider. SOCIAL MEDIA POLICY This outlines my office policies related to use of Social Media. Please read it to understand how I conduct myself on the Internet as a mental health professional and how you can expect me to respond to various interactions that may occur between a client and a psychologistus on the Internet. In most situationsIf you have any questions about anything within this document, I encourage you to bring them up when we meet. As new technology develops and the Internet changes, there may be times when I need to update this policy. If I do so, I will notify you in writing of any policy changes and make sure you have a copy of the updated policy. Friending I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can only release compromise your confidentiality and our respective privacy. It may also 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 part of your 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 by phone. Direct email at xxxxxxxxxxxxxxxxxxxxxxxxxx@xxxxx.xxx is second best for quick, administrative issues such as changing appointment times. See the email section below for more information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advanceregarding email interactions.

Billing and Payments. Your health insurance may cover all or part You are expected to pay for each session at the end of the fees and I will work with session, unless we agree otherwise or unless you to facilitate the exchange of information with your have insurance company for paymentthat requires another arrangement. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour Payment schedules for other professional services you may needwill be agreed to when these services are requested. In circumstances of unusual financial hardship, though I will break down am willing to negotiate a fee adjustment or payment installment plan. I do not accept payment via credit or debit cards. In rare circumstances, I have the hourly cost if option of using legal means to secure payment: hiring a collection agency or going through small claims court (both of which require my disclosing otherwise confidential information). In most collection situations, the only information I work for periods release regarding a client’s treatment is name, nature of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation servicesprovided, and the time spent performing any other service you may request of meamount due. If you become involved such legal action is necessary, legal costs are included in legal proceedings that require my participationthe claim. As indicated above, after an appointment time is scheduled, you will be are expected to pay for all of the appointment 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 charge for the session. Insurance companies do not provide reimbursement for canceled sessions. Based on my professional timeschedule, including preparation and transportation costs and time, even if I am called might not be able to testify by another party. Due to offer you an alternative appointment in the nature of legal involvement, my rate for participation in legal activities is $500 per hoursame week. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what we will assess the resources you have available to pay for your treatment. Because I do not participate in managed care panels, I collect fees directly from clients. If you have a your health insurance policyreimburses you directly, it will usually provide some coverage for mental health treatment. I will provide you with whatever reasonable assistance I can in helping you receive the benefits to which you are entitled; however, you complete required forms and required information. You (not your insurance company) are responsible for full payment of my fees. This includes, but is not limited to, full responsibility for all sessions Please carefully read the section in your insurance coverage booklet that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what describes mental health services in order to determine the extent of your coverage. Your insurance policy coversplan administrator can answer any questions. You are strongly advised Your accessing insurance coverage to contact pay for your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance 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. You should also be aware that your contract with your health insurance company psychotherapy requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosisdiagnosis as well as all session dates. Sometimes Because I am required to do not participate in managed care, I do not provide additional clinical information such as treatment plans or plans, treatment summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide the following specific requested information to your insurance carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client : your name, clinical diagnosis, treatment dates, my fees, and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advancepayments.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. [In circumstances of my professional timeunusual financial hardship, including preparation I may be willing to negotiate a fee adjustment or payment installment plan.] If your account has not been paid for more than 60 days and transportation costs and timearrangements for payment have not been agreed upon, even if I am called have the option of using legal means to testify by another partysecure the payment. Due This may involve hiring a collection agency or going through small claims court which will require 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 nature of services provided, and the amount due. [If such legal involvementaction is necessary, my rate for participation its costs will be included in legal activities is $500 per hour. the claim.] INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance 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 patients feel that they need more services after insurance benefits end. [Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.] You should also be aware that 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies licensed in Montana claim to keep such information confidentialconfidential and protect its privacy, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier, and you are authorizing all third party payors to pay all benefits directly to Xxxxx Xxxxx, LCSW. LIMITS ON CONFIDENTIALITY The law protects Once we have all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide written, advancealways have the right to pay for my services yourself to avoid the problems described above [unless prohibited by contract]. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. CLIENT NAME (PLEASE PRINT) SIGNATURE DATE NAME OF LEGALLY RESPONSIBLE PARENT OR GUARDIAN (WHERE REQUIRED) SIGNATURE DATE NAME AND TITLE OF WITNESS SIGNATURE DATE

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise or unless you have insurance coverage which requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of my professional timeunusual financial hardship, including preparation I may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and transportation arrangements for payment have not been agreed upon, I have the option of using 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 and timewill be included in the claim. In most collection situations, even if the only information I am called to testify by another party. Due to release regarding a patient’s treatment is his/her name, the nature of legal involvementservices provided, my rate for participation in legal activities is $500 per hourand the amount due. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, course I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to 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 patients feel that they need more services after insurance benefits end. [Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.] You should also be aware that your contract with your health insurance company requires that I you authorize me to provide it with information relevant to the services that I provide to you. If you are seeking reimbursement for services under your health insurance policy, you will be required to sign an authorization form that allows me to provide such information. 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this AgreementOnce we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you agree feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above [unless prohibited by contract]. COMMUNICATIONS I am often not immediately available by telephone. While I am usually in my office between 10 AM and 8 PM, I probably will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by voicemail that I monitor daily. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You must understand the risks of contacting me via unsecure means. I may use email communications, text messaging, and leave voicemails for setting appointment times and for sending invoices. I also may use a cell phone for making phone calls. While I do what I can provide requested information to your carrierensure the confidentiality, these methods of communication may not be entirely confidential. For example, I am limited by the policies of my email carrier as well as yours. While it is generally agreed upon that psychotherapy via phone is inadvisable, there may be times when phone consult is necessary outside of regularly scheduled appointment times. Phone consults for crises are typically billed at the same rate as office treatment, prorated by the quarter-hour. Insurance companies do not typically pay for teletherapy or e-therapy and therefore you will be fully financially responsible for the charge. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA and/or Illinois law. However, in the following situations, no authorization is required: • I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice with other mental health professionals and that I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. • I also have contracts with a billing software company and a certified public accountant. As required by HIPAA, I have a formal business associate contract with this/these business(es), in which it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the names of these organizations and/or a blank copy of this contract. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot disclose any information without a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If you file a worker’s compensation claim, and I rendering treatment or services in accordance with the provisions of Illinois Workers’ Compensation law, I must, upon appropriate request, provide a copy of your record to your employer or his/her appropriate designee. There are other some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice. ▪ If I have reasonable cause to believe that require only a child under 18 known to me in my professional capacity may be an abused child or a neglected child, the law requires that I file a report with the local office of the Department of Children and Family Services. Once such a report is filed, I may be required to provide additional information. ▪ If I have reason to believe that an adult over the age of 60 living in a domestic situation has been abused or neglected in the preceding 12 months, the law requires that I file a report with the agency designated to receive such reports by the Department of Aging. Once such a report is filed, I may be required to provide additional information. ▪ If you have made a specific threat or violence against another or if I believe that you present a clear, imminent risk of serious physical harm to another, I may be required disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization your hospitalization. ▪ If I believe that you present a clear, imminent risk of serious physical or mental injury or death to yourself, I may be required to disclose information in order to take protective actions. These actions may include seeking your hospitalization or contacting family members or others who can assist in protecting you. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. You may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. [I am sometimes willing to conduct this review meeting without charge.] In most circumstances, I am allowed to charge a copying fee of $27.91 (base charge), $1.05 per pages 1-25, $0.70 for pages 26-50, and for pages in excess of 50 at $0.35 per page (and for certain other expenses) as required under 735 ILCS 5/8-2006. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 12 years of age and their parents should be aware that the law allows parents to examine their child’s treatment records. Parents of children between 12 and 18 cannot examine their child’s records unless the child consents and unless I find that there are no compelling reasons for denying the access. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. Since parental involvement is often crucial to successful treatment, in most cases, I require that patients between 12 and 17 years of age and their parents enter into an agreement that allows parents access to certain additional treatment information. If everyone agrees, during treatment, I will provide writtenparents with general information about the progress of their child’s treatment, advanceand his/her attendance at scheduled sessions. I will also provide parents with a summary of treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. [In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan.] If your account has not been paid for more than 30 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require 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 nature of services provided, and the amount due. [If such legal action is necessary, its costs will be included in the claim.] Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. Signature of Patient Date Signature of Legal Guardian Date

Billing and Payments. Your health If you have insurance may cover all or part coverage for my services, you will be expected to pay any co-pay at the time of the fees service and I will work with you to facilitate the exchange of information with be billed by my billing service for any balance not covered by your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of mecompany. If you become involved in legal proceedings that require are not using insurance to help pay for my participationservices, you will be expected to pay for all each session at the time it is held. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of my professional timeusing legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, including preparation and transportation costs and timethe only information I release regarding a patient’s treatment is his/her name, even if I am called to testify by another party. Due to the nature of services provided, and the amount due. If such legal involvementaction is necessary, my rate for participation its costs may be included in legal activities is $500 per hourthe claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I If you provide me with your insurance card/information, my billing service will provide you with whatever reasonable assistance I can in helping you receive the benefits to which you are entitledfile claims for you; however, you (not your insurance company) are responsible for full payment of my fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance 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 prior 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 patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that your contract with your health insurance company requires that I provide it with clinical information relevant to the services that I provide to you. I am required to provide a clinical diagnosisdiagnosis and a description of the service provided on particular dates. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this AgreementIt is important to remember that you always have the right to pay for my services yourself to avoid the problems described above, unless prohibited by contract. ADDITIONAL INDIANA LAW REQUIREMENT Indiana law also requires me to inform you agree that I can may only provide requested information those mental health services that I am qualified to your carrierprovide within the scope of my license, certification, and training. LIMITS ON CONFIDENTIALITY The law protects the privacy YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. Name of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advancePatient

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you You are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held unless your insurance coverage requires another arrangement or we have agreed otherwise. For your convenience I accept cash, check and/or credit card (Visa, MasterCard, Discover and American Express) for payment of my professional timefees. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, including preparation and transportation I have the option of using 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 and timewill be included in the claim. In most collection situations, even if the only information I am called to testify by another party. Due to release regarding a patient’s treatment is his/her name, the nature of legal involvementservices provided, and the amount due. Professional Records: You/Your child should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in one set of professional records. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. The laws and standards of my rate profession require that I keep treatment records and Xxxxxx Psychology, LLC maintain them for participation in legal activities seven years past your final date of treatment with me. I use an Electronic Health Record (EHR) for documentation and, when applicable, billing. The systems I use for EHR documentation and billing are TheraNest and Office Ally both of which are HIPAA compliant, confidential systems. Your Rights: HIPAA provides you/your child with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is $500 per hour. INSURANCE REIMBURSEMENT In order for us disclosed to set realistic treatment goals and priorities, it is important to evaluate what resources others; requesting an accounting of most disclosures of protected health information that you have available neither consented to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will provide you with whatever reasonable assistance I can in helping you receive nor authorized; determining the benefits location to which you the protected information disclosures are entitledsent; however, you (not having any complaints that you/your insurance company) are responsible for full payment of child make about my fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by policies and procedures recorded in your insurer. If your insurer does impose records; and the right to a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance 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. 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a paper copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the attached Notice form, and my privacy of all communications between a client policies and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advanceprocedures.

Billing and Payments. Your The client assumes 100% responsibility for all services, including any and all balances from pre- approved insurance coverage. I understand that the fee for this (these) service(s) will be $225 for the initial clinical interview and $175 per hour for subsequent scheduled therapy appointments. Testing is charged at $165 per hour, which includes time administering, scoring, record reviewing and report writing. Payment is due at time of services. The rate of insurance reimbursement varies according to individual insurance contracts and I understand that I will be reimbursed based on my own health plan benefits and that I can request a “superbill” (a more detailed invoice) from Premier so that I may submit bills to my insurance company for said benefits. Though my health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with repay me for additional information regarding payment arrangements. Each client is some of these fees, I understand that I am fully responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation these services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs and time, even if I am called to testify by another party. Due to the nature of legal involvement, my rate for participation in legal activities is $500 per hour. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance 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. 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 aware that missed appointments may be subject to provide a clinical diagnosis. Sometimes I am required charge equal to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part fee of the insurance company files and will probably be stored in a computertherapy appointment. Though all insurance companies claim For Traditional Medicaid/Xxxxxx Care Clients: I understand that my benefits may allow up to keep such information confidential8 units of testing, per calendar year. If they are exhausted at the time of service because I have already had my child evaluated elsewhere within the calendar year, testing is no control over what they do with it once it is in their handslonger considered a covered Medicaid benefit and I may be responsible for payment of these services. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only Your signature below indicates that you provide writtenhave read the information in the Informed Consent to Treatment and agree to abide by its terms during our professional relationship. Client’s Printed Name Client’s Date of Birth Signature of client (or parent/guardian if client is a minor) Date *Email address you authorize PPS to use for correspondence (please print neatly) I, advancethe psychologist or clinician, have discussed the issues above with the client or with the minor client's parent or guardian. My observations of this person's behavior and responses give me no reason, in my professional judgment, to believe that this person is not fully competent to give informed and willing consent of said client or of the minor client's treatment. Signature of Psychologist or Clinician Date

Billing and Payments. Your health insurance may cover all We deeply value our relationship with you! To best provide services for you and our community, BATT recognizes the following patient payment agreement. As we get started, please read each item below to ensure your understanding. For further clarification, please call our office @ 000-000-0000 or part of the fees and I will work with you email us at xxxx@xxxxxxxx.xxx ● A credit/debit card is required to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for be on file to secure payment for services services. FOR YOUR PROTECTION AND PEACE OF MIND, YOUR CREDIT CARD INFORMATION WILL BE SECURED IN OUR ENCRYPTED SYSTEM. ● Copayment, Coinsurance, Deductible, and Self-Pay Patient Fees can be paid by cash, check or credit card. If paying by cash or check (made to “BATT”), please give that to your therapist at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment session. If paying by credit card, your fee will be processed to keep up your card at the end of your session. ● Missed Appointment fees will be automatically charged to your credit/debit card in accordance with the real amount BATT Cancellation and Missed Appointment Policy. ● We appreciate your commitment to stay current on your account while we focus on serving YOU! If you run a balance of our fee agreementgreater than $100, services will be suspended until the balance is paid in full. Please note there Note: There will be a $35 35.00 service charge for all returned checks. Agreement to Pay: By signing this agreement, you accept the fee charged as a legal and lawful debt and agree to pay said fee, including any/all collection agency fees, (33.33%), attorney fees and/or court costs, if such be necessary. You agree, in order for insufficient funds us to service your account or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services collect monies you may needowe, though I will break down the hourly cost if I work for periods of less than one hour. Other services include Birmingham Anxiety and Trauma Therapy and/or our agents may contact you by telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing at any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional timetelephone number associated with your account, including preparation and transportation costs and timewireless telephone numbers, even if I am called which may result in charges to testify you. We may also contact you by another partysending text messages or emails, using any email address you provide to use. Due to the nature Methods of legal involvementcontact may include using pre-recorded/artificial voice messages and/or use of automatic dialing device, my rate for participation in legal activities is $500 per houras applicable. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have are available to pay for your treatment. If you have a health insurance benefits policy, it will usually provide some coverage for mental health treatment. I You are responsible for any portion of the fees not covered by your insurance company. The general process is as follows: You pay your co-pay at time of session, your services are submitted to your insurance company, and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursed. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember that we try to work with insurance companies as a courtesy to you. We will follow up on claims for services rejected by your insurance company only three times. After three rejections, you will be responsible for payment in full. At that time, we will provide you with whatever reasonable assistance I can in helping a superbill if you receive the benefits choose to which you are entitled; however, you (not continue to pursue reimbursement by your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for full payment of my fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services reviewing your insurance policy coversstatements and Explanation of Benefits. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance coveragequestions, you should call your plan administratorand inquire. The number for this inquiry is usually noted on the back of your insurance card at the bottom. Of course, I we will provide you with whatever information I can we can, based on my our experience and will be happy to help try to assist you in understanding deciphering the information you receive from your carrier. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before they will provide reimbursement for mental health services. These plans are often oriented towards a short-term treatment approach, designed to resolve specific problems that are interfering with one’s usual level of functioning. It may be necessary to seek additional approval after a certain number of sessions. In our experience, while quite a lot can be accomplished in short term therapy, many patients feel that more services are necessary after insurance companybenefits expire. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant agreements may require you to the services that I provide to you. I am required authorize us to provide a clinical diagnosis. Sometimes I am required to provide , and sometimes additional clinical information such as a treatment plans plan or summariessummary, or copies in rare cases, a copy of your the entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requestedrecord. This information will become part of the insurance company files files, and in all probability, some of it will probably be stored in a computercomputerized. Though all All insurance companies claim to keep such information confidential, I but once it is in their hands, we have no control over what they do with it once it is in their handsit. I will provide you In some cases, they may share the information with a copy national medical information data bank. Once we have all of any report I submitthe information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits run out before you request itfeel ready to end our sessions. By signing this AgreementIt is important to remember that you always have the right to pay for my services yourself and avoid the complexities that are described above. Please note: Insurance rarely covers forensic psychology services. CONFIDENTIALITY In general, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy confidentiality of all communications between a client patient and a psychologist. In most situationspsychologist is protected by law, I and your therapist can only release information about your treatment to others with the written permission of the patient or his/her guardian. However, there are a number of exceptions: In most judicial proceedings, you have the right to prevent your therapist from providing any information about your treatment. However, in some circumstances, such as child custody proceedings and proceedings in which your emotional condition is an important element, a judge may require your therapist’s testimony if you sign s/he determines that resolution of the issues before him/her demands it. When there is a written Authorization form that meets certain legal requirements imposed by HIPAAcourt order for your therapist’s services, generally the court will expect a report of attendance and progress. There are some situations in which your therapist is legally required to take action to protect others from harm, even though that may require revealing some information about a patient’s treatment. If your therapist believes a minor, an elderly person, or a disabled person is being abused, s/he must file a report with the appropriate state agency. If your therapist believes that a patient is threatening serious bodily harm to another, s/he required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization. If a patient threatens to harm him/herself, the therapist may be required to seek hospitalization of the patient, or to contact family members or others who can help provide protection. Should such a situation occur, your therapist will make every effort to fully discuss it with you before taking any action. Your therapist may occasionally find it helpful to consult about a case with other situations professionals. In these consultations, s/he will make every effort to avoid revealing the identity of any patient. The consultant is, of course, also legally bound to keep the information confidential. Unless you object, s/he will not tell you about these consultations unless s/he feels that require only it is important to your work together. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important to discuss any questions or concerns which you may have as soon as possible. As you might suspect, the laws governing these issues are quite complex and none of the therapists at BATT are attorneys. While we are happy to discuss these issues with you, should you need specific advice, formal legal consultation may be desirable. PROFESSIONAL RECORDS We are required to keep appropriate records of the professional services we provide, and you have the right to review your records. (For more information on this, refer to the HIPAA Privacy Statement.) However, because these records contain information that can be misinterpreted by someone who is not a mental health professional, it is our general policy to discourage patients from viewing their files. Instead, if you request, we will provide writtenyou with a treatment summary unless we believe that to do so would be emotionally damaging. If that is the case, advancewe will be happy to forward the summary to another appropriate mental health professional who is working with you.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise. If any outstanding balances are not paid at the time of my professional timeservice, including preparation fees, copays, missed appointments, charges for miscellaneous services (i.e., letters, document requests, etc.) or if your insurance plan does not pay for the service rendered, your credit card on file will be automatically charged at the end of the business day. We require that you submit credit card information to be securely stored in the client portal for these potential outstanding balances before your first appointment. Payment schedules for other professional services will be agreed to when they are requested. Payments can be made in cash, check or credit card. In circumstances of unusual financial hardship, we may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and transportation arrangements for payment have not been agreed upon, we have the option of using 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, you will be responsible for all costs and timeof collection, even if I am called to testify by another partyincluding reasonable attorneys’ fees. Due to In most collection situations, the only information we release regarding a patient’s treatment is his/her name, the nature of legal involvementservices provided, my rate for participation in legal activities is $500 per hourand the amount due. INSURANCE REIMBURSEMENT The Center for Family and Behavioral Health does not participate with any public or private insurance plans. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually may provide some coverage for mental health and/or health and behavior treatment. I Most insurance policies (but usually not HMOs) have "out-of-network" benefit plans which will reimburse patients directly for some portion of our fees. You are encouraged to contact your insurance company to determine if it provides benefits for out-of-network outpatient mental health treatment. Carefully read the portions of your insurance policy that describe coverage for mental health services. If you have questions about the coverage, call your plan administrator. You are responsible for determining what your insurance will cover, including relevant deductibles and requirements for pre-authorization if needed. It is very important that you find out exactly what Mental Health services your insurance policy covers. As out-of-network providers, we do not process claims or deal with collections from insurers. However, at your request, the Center for Family and Behavioral Health clinician will provide you with whatever reasonable assistance I itemized statements which document your diagnosis, payments and CPT codes so that you can in helping you receive the benefits to which you are entitled; however, you file your own claims. You (not your insurance company) are responsible for full payment of my our fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance 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. 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with ask that you pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. I file insurance claims electronically and your signature on the client services agreement indicates that you give me permission to facilitate the exchange do so. In circumstances of information with your insurance company for payment. Howeverunusual financial hardship, you are ultimately responsible for all fees incurred. You should contact your health insurance company I may be willing to negotiate a fee adjustment or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreementinstallment plan. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services ask me any questions you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, have about billing and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs and time, even if I am called to testify by another party. Due to the nature of legal involvement, my rate for participation in legal activities is $500 per hourpayments. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. It is not as common for insurance policies to cover couples counseling however. If you choose to access your health insurance to cover my services, I will fill out forms and provide you with whatever reasonable assistance I can in helping you receive the benefits to which you are entitled; however. However, you (not your insurance company) are responsible for full payment of my fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what which mental health services your insurance policy covers. You are strongly advised 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 contact your insurance company prior provide services to our first meeting so that you may fully understand once your benefits as they pertain to our work together. end. If at any point you have questions about your insurance coverage, call your plan administrator. Of coursethis is the case, I will provide you with whatever information I can based on do my experience and best to find another provider who will be happy to help you in understanding the information you receive from continue your insurance companypsychotherapy. 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 plan summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreementthe ACKNOWLEDGEMENT OF RECEIPT OF LICSW-CLIENT SERVICES AGREEMENT, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. You will be asked to pay at the end of my professional timeeach session. You may pay in cash, including preparation check, or credit card. You will be given a receipt that provides information an insurer would need if you decide to ask for some type of reimbursement from your carrier. If your account has not been paid for more than 60 days and transportation costs and timearrangements for payment have not been agreed upon, even if I am called have the option of using legal means to testify by another partysecure the payment. Due This may involve hiring a collection agency or going through small claims court which will require 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 nature of services provided, and the amount due. If such legal involvementaction is necessary, my rate for participation its costs will be included in legal activities is $500 per hourthe claim. By signing this agreement, you authorize me to employ the services of an outside collection agent or attorney to seek payment of all unpaid fees. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your Also, please note that I am not on any insurance company prior to our first meeting so panels. I will provide you with a receipt at time of payment that you may fully understand use to request reimbursement from your benefits as they pertain to our work togetherinsurance carrier. You should carefully read the section in your insurance coverage booklet that describes mental health services. If at any point you have questions about your insurance 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 patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that 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 Recordclinical record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects By signing this agreement, you authorize me to provide your health insurance company with all information requested of me pertaining to the privacy services I provide to you or your family member. Xxxx XxXxxxxxxx, Ph.D. is an employee of Children’s Health/Children’s Medical Center. As part of his employment at Children’s, he cannot see individuals who are currently receiving medical or psychiatric care at any of Children’s Health/Children’s Medical Center locations (Plano, Southlake or Dallas), or have received care in the past six months at Children’s. Your signature confirms that your child is not currently receiving medical or psychiatric care at Children’s Health/Children’s Medical Center or has received care in the past six months. Once we have all communications between a client and a psychologist. In most situations, I can only release of the information about your treatment insurance coverage, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide writtenalways have the right to pay for my services yourself to avoid the problems described above. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ABIDE BY ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP. IN ADDITION, advanceYOUR SIGNATURE ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE AND ARE AGREEING TO CONDITIONS SET FORTH IN THE SAFE HARBOR AGREEMENT PORTION OF THIS AGREEMENT. SIGNED Parent Date Parent Date

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held. Payment schedules for other professional services are available upon request. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of my professional timeusing legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, including preparation and transportation costs and timethe only information we release regarding a patient’s treatment is his/her name, even if I am called to testify by another party. Due to the nature of services provided, and the amount due. If such legal involvementaction is necessary, my rate for participation its costs will be included in legal activities is $500 per hourthe claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health Insurance policies vary greatly and we cannot guarantee that your policy will cover psychotherapy or psychological testing. We do not participate in managed care or submit insurance policy, it will usually provide some coverage claims. Receipt of payment statements suitable for mental health treatmentinsurance submission are issued at the end of each month and list all the sessions for that month. I will provide you with whatever reasonable assistance I can in helping you receive the benefits to which you are entitled; howeverHowever, you (not your insurance company) are responsible for full payment of my our fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance coverage, call your plan administrator. Of course, I we will provide you with whatever information I we can based on my our experience and will be happy to help you in understanding the information you receive from your insurance company. You If financial limitations are going to limit your participation in therapy, you should also discuss this with your therapist prior to starting therapy or as soon as such information is available. It is our belief that patients with significant financial limitations are often better served by using in-network providers rather than limiting their access to therapy. If you choose to submit your receipts to your insurance company, you should be aware that your contract with your health insurance company requires that I we provide it with information relevant to the services that I we provide to you. I am required An insurance company or other third-party payor regulated under New Jersey law may request that the patient authorize the psychologist to provide disclose certain confidential information to the third-party payor in order to obtain benefits, only if the disclosure is pursuant to a clinical diagnosisvalid authorization and the information is limited to: Administrative Information, Diagnostic Information, Patient’s Status, Reason for Continuing Services, and Prognosis. Sometimes I am required If the third-party payor has reasonable cause to provide additional clinical believe that the psychological treatment in question may be neither usual, customary nor reasonable, the third-party payor may request, in writing, and compensate reasonably for, an independent review of such treatment by an independent review committee. You should be aware that if your health benefits are provided by a self insured employee benefit plan or other arrangement regulated by the federal ERISA statute, such plan will have considerably more access to information such as treatment plans or summaries, or copies of in your entire Clinical Record. In such situationsThey will not have access to your Psychotherapy Notes. If you have any question about the nature of your health benefits, I will make every effort to release only you should contact the minimum information about you group that is necessary provides the benefits for the purpose requestedyou. 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 we have no control over what they do with it once it is in their hands. I In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any report I we submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. You will be asked to pay at the end of my professional timeeach session. You may pay in cash, including preparation by check, or credit card. You will be given a receipt that provides information an insurer would need if you decide to ask for some type of reimbursement from your carrier. If your account has not been paid for more than 60 days and transportation costs and timearrangements for payment have not been agreed upon, even if I am called have the option of using legal means to testify by another partysecure the payment. Due This may involve hiring a collection agency or going through small claims court which will require 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 nature of services provided, and the amount due. If such legal involvementaction is necessary, my rate for participation its costs will be included in legal activities is $500 per hourthe claim. By signing this agreement, you authorize me to employ the services of an outside collection agent or attorney to seek payment of all unpaid fees. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your Also, please note that I am not on any insurance company prior to our first meeting so panels. I will provide you with a receipt at time of payment that you may fully understand use to request reimbursement from your benefits as they pertain to our work togetherinsurance carrier. You should carefully read the section in your insurance coverage booklet that describes mental health services. If at any point you have questions about your insurance 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 patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that 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 Recordclinical record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects By signing this agreement, you authorize me to provide your health insurance company with all information requested of me pertaining to the privacy services I provide to you or your family member. Once we have all of all communications between a client and a psychologist. In most situations, I can only release the information about your treatment insurance coverage, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide writtenalways have the right to pay for my services yourself to avoid the problems described above. Xxxx XxXxxxxxxx, advancePh.D. is an employee of Children’s Health/Children’s Medical Center. As part of his employment at Children’s, he cannot see individuals who are currently receiving medical or psychiatric care at any of Children’s Health/Children’s Medical Center locations (Plano, Southlake or Dallas), or have received care in the past six months at Children’s. Your signature confirms that you are not currently receiving medical or psychiatric care at Children’s Health/Children’s Medical Center or has received care in the past six months. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ABIDE BY ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP. IN ADDITION, YOUR SIGNATURE ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. SIGNED _____________________________ ____________________ Patient Date _____________________________ _____________________ Xxxxxx XxXxxxxxxx, Ph.D. Date

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for each session at the time it is held, unless agreed to otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. Payments for services can be made by cash, check and credit card. We encourage you to take a receipt for all cash transactions in order to best serve you. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, Vista Psychological & Counseling Centre, LLC, has the option of my professional timeusing legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require the clinician to disclose otherwise confidential information. In most collection situations, including preparation and transportation costs and timethe only information that the clinician will release regarding a client’s treatment is his/her name, even if I am called to testify by another party. Due to the nature of legal involvementservices provided, my rate for participation in legal activities is $500 per hourdates of service, and the amount due. INSURANCE REIMBURSEMENT REIMBURSEMENT: In order for us Vista Psychological & Counseling Centre, LLC, to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I Vista Psychological & Counseling Centre, LLC, will fill out forms and provide you with whatever reasonable assistance I we can in helping you receive the benefits to which you are entitled; however. However, you (not your insurance company) are responsible for full payment of my the clinician’s fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and Vista Psychological & Counseling Centre, LLC, will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, Vista will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require 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 psychotherapy/counseling after a certain number of sessions. While much can be accomplished in short term psychotherapy/counseling, some clients feel that they need more service after insurance benefits end. Some managed‐care plans will not allow the clinician to provide services to you once your benefits end. If this is the case, the clinician will do their best of find another provider who will help you continue your psychotherapy/counseling. You should also be aware that your contract with your health insurance company requires that I the clinician provide it with information relevant to the services that I provide provided to you. I am The clinician is required to provide a clinical diagnosis. Sometimes I am the clinician is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Recordclinical record. In such situations, I the clinician will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have the clinician has no control over what they do with it once it is in their hands. I In some cases, they may share the information with a national medical information databank. The clinician will provide you with a copy of any report I they submit, if you request it. By signing this Agreement, you agree that I the clinician can provide requested information to your insurance carrier. LIMITS ON CONFIDENTIALITY The law protects Once Vista Psychological & Counseling Centre, LLC, has all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, it will be possible to others discuss what can be accomplished with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide writtenalways have the right to pay for the clinician’s services to avoid the potential problems described above. Under changes to HIPAA in 2009, advanceyou now have the right to elect not to use insurance when seeing a therapist and then no information will be disclosed to your insurance company. You should be aware, however, that you have to make such an election prior to each therapy session and you must pay for those services at that time. You will be charged allowable fees under such circumstances.

Billing and Payments. All therapy clients are required to have a credit card on file at WKG or to prepay for services. You will receive a monthly statement for psychotherapy. Your health insurance may cover credit card will be automatically charged for all or part past due balances beyond 60 days of the fees billing Statement date. For assessment, one half (50%) of the estimated testing fee is due on the first day of testing. The balance is due on the day of the interpretive conference unless other arrangements have been made. Reports will not be completed until payment has been received in full. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I will work with you have the option of using legal means to facilitate secure the exchange of information with your insurance company for payment. HoweverThis may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional the only information I release regarding payment arrangements. Each client a patient’s treatment is responsible for payment for his/her name, the nature of services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation servicesprovided, and the time spent performing any other service you may request of meamount due. If you become involved such legal action is necessary, its costs can be included in legal proceedings that require my participation, you will be expected to pay the claim. There is a $50 fee for all of my professional time, including preparation and transportation costs and time, even if I am called to testify any check returned by another party. Due to the nature of legal involvement, my rate for participation in legal activities is $500 per hourbank. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever reasonable assistance I can in helping the necessary billing documentation for you to present to your insurance company to help you receive the benefits to which you are entitled; however. However, you (not your insurance company) are responsible for full payment of my fees. This includes, but is and we are not limited to, full responsibility Preferred Providers for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquireinsurance plan. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised I will ask you to contact fill out an authorization so that I can provide information to your insurance company prior or HMO that will allow me to our first meeting so provide the information necessary to secure payment for the services I provide for you. This Authorization will be in effect for one year, but can be revoked at any time. However, if revoked, I will continue to have the right to forward information necessary to process claims for services already provided. It is important that the insurance company pays you may fully understand and you then pay us. We will not accept payment from insurance companies. You should carefully read the section in your benefits as they pertain to our work together. insurance coverage booklet that describes mental health services. If at any point you have questions about your insurance 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 patients feel that they need more services after insurance benefits end. 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. Under the laws of the District of Columbia, the information that I am required can provide is limited to provide diagnostic information, including a clinical diagnosistreatment plan, the reasons for continuing treatment and the prognosis of how long the treatment will need to continue. Sometimes I am required If the insurance company determines that more information is necessary, the insurance company must appoint an independent reviewer and the additional information can only be disclosed to provide additional clinical information such as treatment the reviewer. You should also be aware that some self- insured employee benefit plans or summaries, or copies of your entire Clinical Recordare not subject to this law. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session no later than the time it is held. Payment schedules for other professional services will be due by the end of my professional timethe month after they occur, including preparation unless another arrangement is agreed to when the services are requested. If your account has not been paid for more than 60 days and transportation costs arrangements for payment have not been agreed upon, I have the option of using legal means to secure payment. This may involve hiring a collection agency or going through small claims court. In most collection situations, the only information I release regarding a client’s treatment is his or her name, billing address, the dates and time, even if I am called to testify by another party. Due to the nature of legal involvementservices provided, my rate for participation and the amount due. Insurance Reimbursement South County Psychological, Inc. accepts some insurances. New contracts are continually being sought, so ask if your plan is accepted. You will be notified if South County Psychological, Inc. is placed on an insurance panel while you are in legal activities is $500 per hour. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a However, some health insurance policy, it will usually provide some coverage for mental health treatmentpolicies do allow you to see a professional who is not in their pre- approved network; this is often referred to as seeing an “out of network provider”. I will provide you with whatever reasonable assistance I can in helping a receipt called a “Super Bill”, which some insurance policies will accept to reimburse you receive the benefits to which you are entitled; howeverfor some or all of your therapy expenses. However, you (not your insurance company) are responsible for full payment of my fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they insurance will reimburse and allow you would like to keep track see an Out of where you are within that limitNetwork Provider, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance coveragethe coverage or if they will reimburse you for therapy expenses with a Super Bill, call your plan administrator. Of courseIf you are eligible for this arrangement and your insurance company requires more information about your treatment, we will discuss the information they want. If you agree to have me provide that information to the insurance company, I will provide need you to sign a Release of Information to allow me to share your information with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. Due to the risking costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. Many managed health care plans require authorization before the service is provided in order for the insurance company to provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot 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 offer you referrals to facilitate your finding another provider with whom you may choose to continue your psychotherapy. You should also be aware that your contract with your health most insurance company requires that I provide it with information relevant companies require you to the services that I provide to you. I am required authorize me to provide them with a clinical diagnosis. Sometimes I am required have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). With your entire Clinical Record. In such situationsauthorization, I will make every effort provide treatment plans and summaries, but I will not provide copies of your entire treatment record to release only the minimum an insurance company, as I feel it grossly violates you right to confidential treatment, as all of that information about you that is necessary for the purpose requested. This information will become becomes a part of the insurance company files and will probably may be stored in on a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, submit if you request it. By signing this AgreementIf your insurance policy will accept a Super Bill and you wish to use your insurance benefits, once you agree have all the information about your insurance coverage, we can discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. Contacting Me I can provide requested information to your carrieram often not immediately available by telephone. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between During many days and Saturdays, I am often with a client and will not answer the phone when I am in session. When I am unavailable, you are free to leave a psychologistmessage on my voice mail. In most situationsI will make every effort to return your calls within 24 hours, with the exception of Sundays, holidays, and when I am on vacation. If I will be unavailable for an extended period of time, I can only release will provide you with information about or leave instructions on my voice mail for you to reach a trusted colleague for assistance if necessary. If you have a life threatening emergency, you must call 911 or go to your treatment nearest emergency room and ask for the psychologist/psychiatrist on call to others if you sign obtain immediate assistance. My voice mail does NOT provide immediate assistance during a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advancelife threatening emergency.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290325* - Late Cancel (within 48 hours for any reason) or No Show: $290325* - 90-minute group therapy session: $8090* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there You will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is notified of this adjustment in addition to the original payment due to meadvance. I also charge $290 325 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs and time, even if I am called to testify by another party. Due to the nature of legal involvement, my rate for participation in legal activities is $500 650 per hour. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance 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. 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advanceadvance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If a client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning the professional services that I provided you, such information is protected by the psychologist-client privilege law. I cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. There are some situations in which I am legally obligated to take actions that I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. • If I have reasonable cause to believe that any child or dependent adult with whom you may have contact or knowledge of has been abused, I am required to file a report with the appropriate government agency. Once such a report is filed, I may be required to provide additional information. • if you threatened violence, I must protect the other person(s) and you by possibly disclosing information about your threat to the appropriate persons and authorities • if you become mentally ill and become unable to take care of your basic needs or become a danger to yourself or others and also refuse treatment, I must report your condition to the authorities • if you provide me with information that another health care provider is not able to practice with reasonable skill and safety due to a mental or physical condition • If a client communicates an imminent threat of serious physical harm to him/ herself, I may be required to disclose information in order to take protective actions. These actions may include initiating hospitalization or contacting family members or others who can assist in providing protection. • if you tell me that you are suffering from an infectious disease, such as HIV, I must report your identity to the local health care officer. • under certain select circumstances the court may order your treatment records be released to another party involved in litigation with you If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. ONLINE VIDEO MEETINGS While my preference is to meet in person, I have discovered that meaningful therapy can indeed take place over video conference. It may be that either of us would prefer to, or need to, meet via video rather than in person, whether due to travel by either you or myself, or for other reasons. In the event that you should prefer to meet over video conference, either on an ongoing or temporary basis, please simply let me know before our session time. I too reserve the right the meet via video should my own schedule necessitate. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to me confidentially by others, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. If I refuse your request for access to your records, you have a right to of review, which I will discuss with you upon request. PATIENT RIGHTS HIPAA provides you with several rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Clients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. Even where parental consent is given, children over age 12 may have the right to control access to their treatment records. While privacy in psychotherapy is very important, particularly with teenagers, parental involvement is also essential to successful treatment, particularly with younger children. For children age 12 and over, I request an agreement between my client and his/her parents allowing me to share general information about the progress of the child’s treatment and his/her attendance at scheduled sessions. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. Statement of Agreement Regarding Fees and Services - Consent: Your signature below indicates that you have read the Notice of Privacy Practices and the information included in this document and agree to abide by this document’s stipulations during our professional relationship. I have read Xx. Xxxxxxxx'x policies and my responsibilities as a client, fee for service, confidentiality, and patient rights. I understand and agree that I will be charged: for any outstanding, unpaid bills; a full session fee for any appointments that I miss for any reason with less than 48 hours notice; and, if I am a member of a couple, for any sessions missed by one or both members of the couple. I have had the opportunity to ask questions and discuss them, and give my informed consent for services. If requested, I have received a copy of this agreement. I agree to abide by the terms therein. Client Name (Printed) Client Signature Date Guardian Name (Printed) (if applicable) Date

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay your co-pay or any appropriate fees for all each appointment at the time it is held (when you check-in for the appointment), unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested by you. [In circumstances of my professional timeunusual financial hardship, including preparation we may be willing to negotiate a fee adjustment or payment installment plan.] We accept cash and transportation costs personal check payments. However, if your check is returned because of lack of funds, closed account or other reason, you will be billed an additional fee to cover our bank charges that we incur because of your returned check. If your account has not been paid for more than 60 days and timearrangements for payment have not been agreed upon, even if I am called we have the option of using legal means to testify by another secure the payment. This may involve hiring a collection agency or going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a patient’s treatment is our name, the patient’s name or responsible party. Due to , the nature of services provided, and the amount due. [If such legal involvementaction is necessary, my rate its costs will be included in the claim and you agree to pay us for participation in legal activities is $500 per hour. those costs.] INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I We will fill out forms and provide you with whatever reasonable assistance I we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my our fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you contact your insurance company to find out exactly what mental and other health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I we will provide you with whatever information I we can based on my our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, we may be willing to call the company on your behalf. Please turn to the next page 4 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 patients feel that they need more services after insurance benefits end. [Some managed-care plans may not allow us to provide services to you once your benefits end. If this is the case, we will do our 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 we provide it with information relevant to the services that I we provide to you. I am We are required to provide a clinical diagnosis. Sometimes I am we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I we have no control over what they do with it once it is in their hands. I In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any report I we submit, if you request it. By signing this Agreement, you agree that I we can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects Once we have all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide written, advancealways have the right to pay for our services yourself to avoid the problems described above [unless prohibited by contract]. Print Patient’s Name on this line: / / Date Patient’s Signature / / Date Parent or Legal Guardian’s Signature (if applicable)

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless you and your therapist agree otherwise or unless you have insurance coverage, which requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of my professional timeunusual financial hardship, including preparation your therapist may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and transportation arrangements for payment have not been agreed upon, we have the option of using 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 and timewill be included in the claim. In most collection situations, even if I am called to testify by another party. Due to the only information we release regarding a client’s treatment is his/her name, the nature of legal involvementservices provided, and the amount due. Therapist utilize varying forms to accept payment such as cash, credit card, personal checks, and mobile payment applications. CREDIT CARD AUTHORIZATION I have provided my rate 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 participation 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 credit card will be made and kept in legal activities is $500 per hourmy 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: INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I We will provide you with whatever reasonable assistance I we can in helping you receive the benefits to which you are entitledbenefits; however, you (not your insurance company) are responsible for full payment of my fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I will We can provide you with whatever information I can based on my our experience with other clients and will be happy try to help you in understanding the information you receive from your insurance companycompany 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 your contract most insurance companies require that we provide them 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 we have to provide additional clinical information such as treatment plans or summaries, or copies of your the entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requestedrecord. 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 we have no control over what they do with it once it is in their hands. I will In some cases, they may share the information with a national medical information databank. Your therapist can provide you with a copy of any report I reports they submit, if you request it. By signing this AgreementNot all therapist accept insurance or participate in health insurance panels. Some therapist may provide “out-of-network” services. In these instances, you agree that I they can provide requested information you with a receipt of payment which you may then use to file a claim for out-of- network benefits. However, your carriertherapist is not required to file the claims for out-of-network services in place of the client. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment It is important to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only remember that you provide written, advancealways have the right to pay for services yourself to avoid the issues described above. I choose NOT to utilize my insurance coverage at this time. INITIALS I choose to utilize insurance and will submit receipts of payment to my insurance provider.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. (In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan). You will be responsible for all charges denied and/or not covered by insurance. Please make all checks payable to Sea Change, LLC and/or Xxxxxxxx X. Xxxxxx, MA, LPC. There is a $25.00 fee for any returned checks. If your account has not been paid for longer than 60 days, and arrangements for payment have not been agreed upon, I have the option of my professional timeusing 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, including preparation and transportation its costs and timewill be included in the claim). In most collection situations, even if the only information I am called to testify by another party. Due to release regarding a patient’s treatment is his/her name, the nature of legal involvementservices provided, my rate for participation in legal activities is $500 per hourand the amount due. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I will provide you with whatever information I can can, based on my experience experience, and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I would be willing to call the insurance company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans, 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. You should also be aware that your contract with your health most insurance company requires that I provide it with information relevant companies require you to the services that I provide to you. I am required authorize me to provide them with a clinical diagnosis. Sometimes I am required to provide have provided additional clinical information information, such as as, treatment plans or summaries, or copies of your the entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requestedrecord (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though Although all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their handspossession. In some cases, they may share the information with a National Medical Information Databank. I will provide you with a copy of any report that I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects Once we have all the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above (unless prohibited by contract). CONTACTING ME I am often immediately available by telephone. While I am in my office and with a client, I will not answer the phone. When I am unavailable, my telephone is answered by a voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it. If you are difficult to reach, please inform me of some times when you will be available. Any telephone conversations lasting longer than 5 minutes will result in a fee of $1.00 per minute. In emergencies, if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the counselor/therapist/psychiatrist on-call. In addition, you may also call the help line at (602) 254-HELP (4357). If I will be unavailable for an extended time (ie. vacation, conferences, etc.), I will provide writtenyou with the name of a colleague to contact should it become necessary. PROFESSIONAL RECORDS As I am sure you are aware, advanceI am required to keep records of our work together. As these records contain information that can be misunderstood by someone who is not a mental health professional, it is my general policy that patients may not review them; however, I will provide, at your request, a treatment summary, unless I believe that to do so would be emotionally damaging. If that is the case, I will be happy to send the summary to another mental health professional that is working with you.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of my professional timeunusual financial hardship, including preparation I may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than sixty (60) days and transportation costs and timearrangements for payment have not been agreed upon, even if I am called have the option of using legal means to testify by another partysecure the payment. Due This may involve hiring a collection agency or going through small claims court 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 involvementaction is necessary, my rate for participation its costs will be included in legal activities is $500 per hourthe claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it It is important to evaluate what resources remember that you always have available the right to pay for your treatmentmy services yourself to avoid the problems described below. 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 reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance the coverage, call your plan administrator. Of courseIt 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 provide you with whatever information I can based on do my experience and best to find another provider who will be happy to help you in understanding the information you receive from continue your insurance companypsychotherapy. You should also be aware that your contract with your health insurance company requires that I you authorize me to provide it with information relevant to the services that I provide to you. If you are seeking reimbursement for services under your health insurance policy, you will be required to sign an authorization form that allows me to provide such information. I am required to provide a clinical diagnosis. Sometimes Sometimes, I am required will be requested to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. This may require an additional authorization. (If you refuse such authorization, the insurance company can deny your claims and you will be responsible for paying for services yourself.) In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only Your signature below indicates that you provide written, advancehave read the information in this document and agree to abide by its terms during our professional relationship. Signature of Client/Guardian/Representative Date Signed

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of my professional timeunusual financial hardship, including preparation I may be willing to negotiate a payment installment plan. If your account has not been paid for more than 60 days and transportation costs and timearrangements for payment have not been agreed upon, even if I am called have the option of using legal means to testify by another partysecure the payment. Due This may involve hiring a collection agency or going through small claims court which will require 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 nature of services provided, and the amount due. If such legal involvementaction is necessary, my rate for participation its costs will be included in legal activities is $500 per hourthe claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance 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 patients feel that they need more services after insurance benefits end. 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects Once we have all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide written, advancealways have the right to pay for my services yourself to avoid the problems described above [unless prohibited by contract].

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment Payment for services is the patient’s responsibility and due at each sessionthe time of service unless you have insurance coverage that requires another arrangement (see Insurance Reimbursement below). - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour Payment schedules for other professional services you will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may needinvolve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, though the only information I will break down release regarding a patient’s treatment is his/her name, the hourly cost if I work for periods nature of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation servicesprovided, and the time spent performing any other service you may request of meamount due. [If you become involved in such legal proceedings that require my participationaction is necessary, you its costs will be expected included in the claim.] Any balances due in excess of 90 days are subject to pay for all of my professional time, including preparation and transportation costs and time, even if I am called to testify by another party. Due to the nature of legal involvement, my rate for participation in legal activities is $500 per hourinterest being added. INSURANCE REIMBURSEMENT In order for us It is the patient’s responsibility to set realistic treatment goals verify the details of your mental health coverage with your insurance company(ies) and prioritiesto determine if an authorization is required. (Note: Other information you may want to obtain from your insurance company might be: deductible amounts, it reimbursement amounts, if authorization is important to evaluate required, number of visits allowed per benefit year, what resources are the dates of the benefit year, if a referral from your primary care physician or a psychiatrist is required, yearly and lifetime maximum reimbursement amounts, etc. When consulting with your insurance company, advise them that you have available to pay for are requesting out-of-network, mental health information.) You should carefully read the section in your treatmentinsurance coverage booklet that describes mental health services. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance 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. Some insurance companies 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 patients feel that they need more services after insurance benefits end. Please be advised that I am an "out-of-network" provider with insurance companies. I will provide you with the completed forms for you to file; 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. Any balances due in excess of 90 days are subject to interest being added. Please discuss the details of secondary or supplemental insurance reimbursement with me or the appropriate business associate that handles this for me. It is your responsibility to advise us if you have a change of address, phone number(s), insurance coverage, and/or place of employment so that we can update our file for account accuracy. PLEASE BRING YOUR INSURANCE CARD TO YOUR FIRST APPOINTMENT. You should also be aware that 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment It is important to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only remember that you provide written, advancealways have the right to pay for my services yourself to avoid the problems described above [unless prohibited by contract].

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of my professional timeusing legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, including preparation and transportation costs and timethe only information we release regarding a patient’s treatment is his/her name, even if I am called to testify by another party. Due to the nature of services provided, and the amount due. If such legal involvementaction is necessary, my rate for participation the costs will be included in legal activities is $500 per hourthe claim. INSURANCE REIMBURSEMENT In order for us Insurance Information Xxxxx & Associates Therapists accept these insurances (but please call your insurance carrier to verify your plan with each therapist): AETNA American Behavioral Blue Cross Blue Shield of Alabama Behavioral Health Systems Cigna Cigna HealthSpring Medicare Multi Plan/PHCS OPTUM/UBH/UHC Tricare Out of State BCBS Plans Beacon Insurance Reimbursement So that we can set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I We will file your insurance claim and provide you with whatever reasonable assistance I we can in helping you receive the benefits to which you are entitled; : however, you (not your insurance company) are responsible for full payment of my our fees. This includesAs stated earlier, but is not limited toyou must call your insurance company to verify coverage and obtain pre-authorization (if required) before the first visit, or you will be asked to pay full responsibility fee for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like the first visit Due to keep track the rising costs of where you are within that limithealth care, it is your responsibility to contact the insurer to inquireinsurance benefits have increasingly become more complex. It is very important that you find out sometimes difficult to determine exactly what 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 patients feel that they need more services your after insurance policy coversbenefits end. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance coverageAt this point, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and the client will be happy required to help you pay full fee out of pocket, unless the MHP and client discuss a reduced fee in understanding advance of the information you receive from your insurance companyfirst non-covered session. You should also be aware that your contract with your health insurance company requires that I we provide it with information relevant to the services that I we provide to you. I am We are required to provide a clinical diagnosis. Sometimes I am we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I we have no control over what they do with it once it is in their hands. I In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any report I submit, we submit if you request it. By signing this Agreement, and the accompanying Authorization, you agree that I we can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects Once we have all the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide writtenalways have the right to pay for our services yourself to avoid the problems described above. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS. YOUR SIGNATURE ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE Printed name of Patient Signature of Patient (Parent or legal guardian, advanceif child is under age 14) Date signed Revised 4/21 Pitts&Associates I N C O R P O R A T E D 000 Xxxxxx Xxxxxxx Xxxx, Xxxxx 000 Xxxxxxxxxx, XX 00000 Office 000.000.0000 Fax 000.000.0000 xxx.XxxxxxxxXxxxxxx.xxx I. • • − − − • •

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of my professional timeusing legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, including preparation and transportation costs and timethe only information we release regarding a patient’s treatment is his/her name, even if I am called to testify by another party. Due to the nature of legal involvementservices provided, my rate for participation in legal activities is $500 per hourand the amount due. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I We will complete forms and provide you with whatever reasonable assistance I we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my our fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes outpatient mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I our staff will provide you with whatever information I we can based on my our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, one of our staff will 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 patients feel that they need more services after insurance benefits end. In this case your therapist will discuss payment options with you for future sessions. You should also be aware that your contract with your health insurance company requires that I we provide it with information relevant to the services that I we provide to you. I am In these situations your therapist is required to provide a clinical diagnosis. Sometimes I am we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I we have no control over what they do with it once it is in their hands. I will provide you In some cases, it is possible that they may share the information with a copy of any report I submit, if you request itnational medical information databank. By signing this Agreement, you agree that I your therapist can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects Once we have all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide written, advancealways have the right to pay for services yourself to avoid the problems described above. CLIENT CONSENT TO TREATMENT I have read and received the Notice of Privacy Policies form and the Psychotherapy Services Agreement carefully; I understand them and agree to comply with all of the policies and procedures described in these documents. Client Name (please print) Client Signature (if 18 or older) Date Parent/Guardian Signature Date Parent/Guardian Signature Date

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless your doctor agrees other- wise or unless you have insurance coverage, which requires another arrangement. If you have insur- ance, your copay is due at the time of my your session. Payment schedules for other professional timeservices will be agreed to when they are requested. In circumstances of unusual financial hardship, including preparation we may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and transportation arrangements for payment have not been agreed upon, we have the option of using 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 and timewill be included in the claim. In most collection situations, even if I am called to testify by another party. Due to the only information we release re- xxxxxxx a patient’s treatment is his/her name, the nature of legal involvementservices provided, my rate for participation in legal activities is $500 per hourand the amount due. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I Your doctor will fill out forms and provide you with whatever reasonable assistance I they can in helping you receive the benefits to which you are entitled; howeverhow- ever, you (not your insurance company) are responsible for full payment of my your doctor’s fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I course your doc- tor will provide you with whatever information I they can based on my their experience and will be happy to help you in understanding the information you receive from your insurance company. You should also If it is neces- sary to clear confusion, your doctor will be aware willing to call the company on your behalf. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end sessions. It is important to remember that you always have the right to pay for your contract with your health insurance company requires that I provide it with information relevant doctor’s services yourself to avoid the problems described above [unless prohibited by contract]. CONTACTING YOUR DOCTOR Your doctor may not be immediately available by telephone. Usual business hours are weekdays be- tween 8 AM and 5 PM. Due to the services nature of their work, doctors will not answer the phone when with a patient. When unavailable, your doctor’s telephone is answered by confidential voice mail that I provide to youis monitored frequently. 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. In such situations, I Your doctor will make every effort to release only return your call on the minimum information about same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform your doctor of some times when you will be available. Your doctor cannot respond to emergencies on the phone. If you are unable to reach your doctor and feel that is necessary you can’t wait for your doctor to return your call, contact your family physician or the nearest emergency room and ask for the purpose requestedpsychologist or psychiatrist on call or go to the nearest emergency room. This information You may contact the 24-hour Crisis Hot- line at (000) 000-0000. If your doctor 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 confidentialunavailable for an extended time, I have no control over what they do with it once it is in their hands. I will provide you with the name of a copy of any report I submitcolleague to contact, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advancenecessary.

Billing and Payments. Your health insurance may cover all or part You are expected to pay for each session at the end of the fees and I will work with session, unless we agree otherwise or unless you to facilitate the exchange of information with your have insurance company for paymentthat requires another arrangement. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour Payment schedules for other professional services you may needwill be agreed to when these services are requested. In circumstances of unusual financial hardship, though I will break down might be willing to negotiate a fee adjustment or payment installment plan. In rare circumstances, I have the hourly cost if option of using legal means to secure payment: hiring a collection agency or going through small claims court (both of which require my disclosing otherwise confidential information). In most collection situations, the only information I work for periods release regarding a client’s treatment is name, nature of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation servicesprovided, and the time spent performing any other service you may request of meamount due. If you become involved such legal action is necessary, legal costs are included in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs and time, even if I am called to testify by another party. Due to the nature of legal involvement, my rate for participation in legal activities is $500 per hourclaim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what we will assess the resources you have available to pay for your treatment. Because I do not participate on managed care panels, I collect fees directly from clients. If you have a your health insurance policyreimburses you directly, it will usually provide some coverage for mental health treatment. I will complete forms and provide you with whatever reasonable 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 your fees. This includes, but is not limited to, full responsibility for all sessions You should carefully read the section in your insurance coverage booklet that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what describes mental health services in order to determine the extent of your coverage. Your insurance policy coversplan administrator can answer any questions. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance 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 experience; I can assist you in understanding deciphering the information you receive from insurance information. Your accessing insurance coverage to pay for your insurance company. You should also be aware that your contract with your health insurance company psychotherapy requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosisdiagnosis as well as all session dates. Sometimes Because I am required to do not participate in managed care, I do not provide additional clinical information such as treatment plans or summaries, summaries or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide the following specific requested information to your insurance carrier: your name, clinical diagnosis, treatment dates, and fees. LIMITS ON CONFIDENTIALITY INFORMATION ABOUT TECHNOLOGY I attempt to avoid using technology as much as possible based on privacy and confidentiality issues. Internet technology is not private or confidential. The law protects most effective means of contacting me between sessions is via phone and voice mail: (000) 000-0000. Clients may leave a message on my cell phone 24 hours per day. Although my main communication modality is my cell phone (I have no land line), please be aware that cell phones are not completely private or confidential. I attempt to use my cell phone only for administration purposes such as making and changing appointment times. I prefer person-to-person conversations rather than text messaging; in the privacy of all communications between rare occasion that I receive a client and a psychologist. In most situationstest message, I can will return the message via the phone line. Occasionally, I use my cell phone for brief emergency phone conversations; please know that this modality is not completely private or confidential. My only release information about your treatment to others if you sign e-mail address is through Antioch University Seattle. I do not have an e-mail address connected with my private practice. I do not use e-mail for contact with clients because the Internet is not private or confidential. I do not have a written Authorization form that meets certain legal requirements imposed by HIPAAwebsite for my practice. There are other situations that require only I do not access social media sites. FILING A COMPLAINT Filing a complaint is done through the following agencies: Washington Department of Health, Licensing Board, P. O. Box 47869, Olympia, WA 98504-7869; (000) 000-0000 Washington State Psychological Association, P. O. Box 2016, Edmonds, WA 98020-9516, (000) 000-0000; (000) 000-0000 Secretary, U. S. Department of Health & Human Services, 000 Xxxxxxxxxxxx Xxxxxx, X. X., Xxxxxxxxxx, XX 00000, (000) 000-0000; (000) 000-0000 SIGNATURES AND AGREEMENT Your signature below indicates that you provide writtenhave read the information in this document and agree to abide by its terms during our professional relationship, advancewith specific attention to the two items below: I have been advised about the meaning of the diagnostic category reported to the insurance carrier (when applicable). I agree to a session fee of $ , to be paid each session unless otherwise negotiated. A monthly 1% service fee will be attached to an accrued balance. When I increase these fees, I will offer a month’s notice during which we can discuss the impact of this increase. _ Client signature Date Client signature Date Psychologist signature Date

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In order to streamline billing and minimize the possibility of financial matters intruding on the therapeutic relationship, I agree to place a currently valid credit card on file with HCP and authorize HCP to make appropriate charges on that card for services rendered on or shortly after the date of service. If I choose a different form of payment, I will present cash or another valid credit card prior to my professional timesession. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, including preparation and transportation costs and timeyour doctor has the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require disclosure of otherwise confidential information. In most collection situations, even if I am called to testify by another party. Due to the only information the doctor releases regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal involvementaction is necessary, my rate for participation its costs will be included in legal activities is $500 per hourthe claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I Your doctor will fill out forms and provide you with whatever reasonable assistance I s/he can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my your doctor’s fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I your doctor will provide you with whatever information I s/he can based on my his/her experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, your doctor will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require 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 patients feel that they need more services after insurance benefits end. You should also be aware that your contract with your health insurance company requires that I your doctor provide it with information relevant to the services that I provide s/he provides to you. I am Your doctor is required to provide a clinical diagnosis. Sometimes I am s/he is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I s/he will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have your doctor has no control over what they do with it once it is in their hands. I In some cases, they may share the information with a national medical information databank. Your doctor will provide you with a copy of any report I submits/he submits, if you request it. By signing this Agreement, you agree that I your doctor can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects Once we have all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide written, advancealways have the right to pay for your doctor’s services yourself to avoid the problems described above unless prohibited by contract.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise or unless you have insurance coverage which requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. (In circumstances of my professional timeunusual financial hardship, including preparation I may be willing to discuss negotiating a fee adjustment. This arrangement will be subject to periodic review.) If your account has not been paid for more than 60 days and transportation arrangements for payment have not been agreed upon, I have the option of using 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 and timewill be included in the claim.] In most collection situations, even if the only information I am called to testify by another party. Due to release regarding a patient's treatment is his/her name, the nature of legal involvementservices provided, my rate for participation in legal activities is $500 per hourand the amount due. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will provide you with whatever reasonable assistance I can in helping you receive the benefits to which you are entitled; , however, you (not your insurance company) are ultimately responsible for full payment of my fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, please call your plan administrator. Of course"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 a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. [Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will provide you with whatever information I can based on do my experience and best to find another provider who will be happy to help you in understanding the information you receive from continue your insurance company. psychotherapy.] You should also be aware that your contract with your health most insurance company requires that I provide it with information relevant companies require you to the services that I provide to you. I am required authorize me to provide them with a clinical diagnosis. Sometimes I am required have to provide additional clinical information such as treatment plans or summaries, or copies of your the entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requestedrecord (in rare cases). 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 have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects Once we have all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, we will discuss what we can expect to others if accomplish with the benefits that are available. You have the right to pay for my services yourself exclusively, in order to avoid potential concerns about confidentiality with your private health information.. CONTACTING ME I am often not immediately available by telephone. I will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by a voicemail that I monitor frequently. I will make every effort to return your call on the same day you sign make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me, can’t wait for a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only return call, and/or believe that you provide writtenare in an emergency situation, advanceI ask that you please go to your nearest emergency room.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of my professional timeunusual financial hardship, including preparation I may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and transportation costs and timearrangements for payment have not been agreed upon, even if I am called have the option of using legal means to testify by another partysecure the payment. Due This may involve hiring a collection agency or going through small claims court 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 involvementaction is necessary, my rate for participation its costs will be included in legal activities is $500 per hourthe claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually often provide some coverage for mental health treatmenttreatment with out of network providers like myself. I will fill out forms and provide you with whatever reasonable 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. This includesIt is sometimes difficult to determine exactly how much mental health coverage is available. Some insurance plans 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, but is some clients feel that they need more services after insurance benefits end. Some managed-care plans will not limited to, full responsibility for all sessions that exceed any session limits imposed by allow me to provide services to you once your insurerbenefits end. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it this is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance coverage, call your plan administrator. Of coursecase, I will provide you with whatever information I can based on do my experience and best to find another provider who will be happy to help you in understanding the information you receive from continue your insurance companypsychotherapy. 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 youcertain information. I am always required to provide a clinical diagnosis. Sometimes I am , and sometimes required to provide additional clinical information such as treatment plans or plans, treatment summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects Once we have all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide writtenalways have the right to pay for my services yourself to avoid the problems described above, advanceunless prohibited by contract. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. Name (please print): Signature: Date: Address: E-mail: Phone: Date of Birth: Emergency Contact:

Billing and Payments. Your health insurance may cover all We accept credit cards, debit cards, HSA cards, and FSA cards. No checks or part cash are accepted. Before scheduling your first session, information for an active credit, debit, HSA, or FSA card is required and will be truncated and securely stored by a third-party bankcard processor, Pineapple Payments/CardConnect, to meet Payment Card Industry (PCI) requirements. Please be advised that your card for each session will be charged after the session has been held unless we agree otherwise. Payment schedules for other professional services will be agreed to 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 of this and further sessions will not be scheduled until the fees and I will work with balance is paid in full. If your credit, debit, HSA, or FSA card on file has expired, we require you to facilitate replace it with an active card before your next session is scheduled. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the exchange option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If this should occur, its 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 we will release regarding a patient’s treatment is his/her name, the dates, times, and nature of services provided, and the amount due. APPOINTMENTS Your scheduled time is reserved for you. If you arrive late, your session 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 regular rate. Please be aware that the procedure code for telehealth 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 company 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 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) for paymentany 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, no-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 responsibility to ensure we have received your cancellation or rescheduling request which you may do by telephone, email, or in-person communication. Inclement Weather We will provide you notification as soon as we can whether we will be able see patients in the 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 will be an option. COMMUNICATION AND INTERNET-RELATED ISSUES We are often not immediately available by telephone or email since we will not answer the telephone or check emails when we are with a patient. When we are unavailable, please leave us a voicemail or an email message; we monitor both frequently. We will make every effort to return your message within 24 hours with the exception of weekends and holidays. If you are difficult 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 ultimately responsible 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 all fees incurredus 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 should contact your health insurance company 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 consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due email and text message reminders. Besides sending appointment reminders via text message, we do not send text messages to mepatients nor do we respond to text messages from anyone in treatment. I For email communication besides the appointment reminders we send through SimplePractice, we also charge $290 per hour for other professional services 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 need, though I will break down compromise the hourly cost if I work for periods privacy and confidentiality of less than one hourthe email. Other services include The telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request or face- to-face context is much more secure as a mode of mecommunication. If you become involved 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 legal proceedings that require 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 participationresponse may be intercepted. Furthermore, you will should be expected aware that all emails we receive from you and send to pay for all of my professional time, including preparation and transportation costs and time, even if I am called to testify by another party. Due to the nature of legal involvement, my rate for participation in legal activities is $500 per hour. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will provide you with whatever reasonable assistance I can in helping you receive the benefits to which you are entitled; however, you (not filed in your insurance company) are responsible for full payment patient chart and will thus become part of my fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurerlegal record. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limitpersonal contact information (e.g., telephone number, email address) changes, it is your responsibility to contact the insurer inform us of these changes as soon as possible so as not to inquiremiss appointment reminders, etc. It We am not responsible for charges associated with such changes. P atient Portal Your secure patient portal is very important xxxxx://xxxxxxxxxxxxxxx.xxxxxxxxxxxx.xx/. 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 xxxxx://xxx.xxxxxxxxxxxxxx.xxx/privacy/. W ebsite We have a website that you find out exactly what mental health services your insurance policy coversare free to access: xxx.xxxxxxxxxxxxxxx.xxx. We use it for professional reasons to provide information to others about us and the practice. You are strongly advised welcome to contact your insurance company prior to access and review the information that we have on our first meeting so website. S ocial Media We may participate on social networks but not in our professional capacity. If you have an online presence, there is a possibility that you may fully understand your benefits as they pertain to our work togetherencounter us by accident. . If at any point you have questions about your insurance 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. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant Due 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 importance of your entire Clinical Record. In such situationsconfidentiality and the importance of minimizing dual relationships, I will make every effort we do not accept friend or contact requests or respond to release only the 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 confidentialany messages from current or former patients on any social networking site (Facebook, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submitLinkedIn, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advanceetc.).

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee expected to pay for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and each session at the time spent performing any other service you may request of meit is held unless we agree otherwise. If you become involved in legal proceedings that require my participationI am billing your insurance, you will be expected to pay your deductible, co-insurance, and/or co-pay at each session. Co-pay and co-insurance amounts vary depending upon your insurance policy. If your account has not been paid for all more than 30 days and arrangements for payment have not been agreed upon, I may assess a 5% late fee per month. I also have the option of my professional timeusing legal means to secure payment. In most collection situations, including preparation and transportation costs and timethe only information I would release regarding a patient’s treatment is his/her name, even if I am called to testify by another party. Due to the nature of services provided, and the amount due. If such legal involvementaction is necessary, my rate for participation its costs will be included in legal activities is $500 per hourthe claim. INSURANCE REIMBURSEMENT In order for For us to set realistic treatment goals and prioritiesgoals, it is important to we must evaluate what your available resources you have available to pay for your treatment. If you have a health insurance policyinsurance, it will usually provide some coverage for mental health treatmenttreatment coverage. I will bill your primary insurance carrier if possible and provide you with whatever reasonable assistance I can in helping you receive the benefits to which you are entitled; . Please keep in mind, however, you (that you, not your insurance company) , are responsible for full payment of my fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you we find out exactly what mental health services your insurance policy covers, and what deductibles or co-pay/co-insurance fees are considered your responsibility. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance coverage, call your our plan administratoradministrator or customer service number. Of course, I will provide you with whatever information I can based on my experience and experience, will be happy to help you in understanding understand the information you receive from your insurance company, and if necessary, will call the company on your behalf to ascertain coverage. It may be difficult to determine exactly how much mental health coverage is available in advance because many “Managed Health Care” plans require authorization before they provide reimbursement and require approval for more therapy after a certain number of sessions. You should also be aware that your contract with your most health insurance company requires companies require that I provide it with furnish information relevant to about the services that I provide to you. I am required to provide , including a clinical diagnosis. Sometimes In addition, some plans require that I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will discuss your insurance company’s requirements with you, and make every effort to release only the minimum information about you that is necessary for the purpose requestednecessary. This information will become becomes part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidentialfiles, over which I have no control over what control. In some cases, they do may share information with it once it is in their handsmedical information data banks. I will provide you with a copy of any report I submit, if you request it. By signing this Agreementagreement, you agree that I can provide requested information to your carrierinsurance plan if I am billing your insurance for your psychotherapy services. Once we know about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available to you. While much can be accomplished in time-limited or short-term therapy, some patients choose to continue psychotherapy after their insurance benefits have ended. I am happy to discuss self-pay arrangements with you. You always have the right to choose to pay for services yourself without using insurance. CONTACTING ME Often I am not immediately available by telephone. When I am in my office I do not answer the phone when I am with a patient. My telephone (000-000-0000) is answered by a confidential voicemail that I monitor until 9pm Monday through Friday. I will make every effort to return your call on the same business day, and on the following business day for calls received on weekends and holidays. If you are difficult to reach, please inform me of times when you will be available. When I am unavailable for an extended period of time, I will provide you with the name of a colleague to contact if necessary. In ca se of an emergency, if you are unable to reach me and feel that you cannot wait for me to return your call, contact your physician, go to the nearest emergency room or psychiatric emergency service, or call 911. If you are seeing me for adjunctive EMDR, please contact your primary therapist for emergencies that may arise. If you feel you need greater emergency phone availability, I can provide you with names of other mental health professionals or clinics that provide 24-hour telephone crisis coverage. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a psychologist. In most situations, I can only release information about your treatment to others only if you sign a written Authorization authorization form that meets certain legal requirements imposed defined by HIPAA. Other situations require only your written, advance consent. Your signature on this Agreement provides consent for these activities, as follows: • Consultation with other health and mental health professionals regarding my practice. During consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record. • Consultation with other psychotherapy or psychopharmacology professionals that you currently see to coordinate your care. The other professionals are also legally bound to keep the information confidential. If you have any concerns about this consultation, please discuss them with me. • Disclosures required by health insurers or to collect overdue fees, discussed elsewhere in this Agreement In some situations I am permitted or required to disclose information without your consent or authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation or disability claim, I must, upon appropriate request, provide appropriate information, including a copy of the patient’s record, to the patient’s employer, the insurer, or the Department of Worker’s Compensation. There are other some situations in which I am legally obligated to take actions when I believe my actions are necessary to attempt to protect others from harm. In these situations, I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice. • If I have reason to believe that require only a child under age 18 is suffering from physical, emotional, or sexual abuse, or from neglect (including malnutrition), the law requires that I file a report with the Connecticut Department of Social Services. Once such a report is filed, I may be required to provide additional information. • If I have reason to believe an elderly or handicapped individual is suffering from abuse, the law requires that I report this to the Connecticut Protective Services for the Elderly. Once such a report is filed, I may be required to provide additional information. • If a patient communicates an immediate threat of serious physical harm to an identifiable victim, or if a patient has a history of violence and the apparent intent and ability to carry out such a threat of serious physical harm, I may be required to take protective actions. These may include notifying the potential victim, contacting the police, and/or seeking hospitalization for the patient. • If a patient threatens to harm him/herself, I may be obligated to seek evaluation and/hospitalization for him/her, or to contact family members or others who can help provide protection. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will attempt to limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you provide writtenmay have now or in the future. The laws governing confidentiality can be quite complex, advanceand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPPA, I have a Clinical Record (CR) for you. It includes information about your reasons for seeking therapy, a description of your problems and their impact on your life, your medical and social history, your treatment history, your diagnosis, our treatment goals, and your progress towards these goals. In addition, the CR includes any past treatment records that I received from other providers, reports of a any professional consultations, and any reports that have been sent to anyone, including reports to your insurance carrier. If you request in writing, you have the right to examine and/or receive a copy of your CR. Because these are professional records that can be misinterpreted and/or be upsetting to untrained readers, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In situations where I believe that access to your records would adversely affect your well-being, you have a right to a summary and to have your record sent to another mental health provider or your attorney. If I refuse your request for access to your records, you have a right to request a review of my refusal, which I will discuss with you upon your request. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your CR and disclosures of PHI. These include the right to: • Request that I amend your record • Request restrictions on what information from your CR is disclosed to others • Ask for an accounting of most PHI disclosures that you have not consented to nor authorized • Determine the location to which PHI disclosures are sent • Have any complaints you make about my policies and procedures recorded in your records, and • Receive a paper copy of this Agreement, the “Notice of Policies and Practices to Protect the Privacy of Your Health Information”, and information about my privacy policies and procedures. I am happy to discuss any of these rights with you.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise or you have insurance coverage that I accept. Payment schedules for other professional services will be agreed to at the time these services are requested. Insurance plans typically assign a co-pay amount to be paid by the insured, and may also require that the insured pay any sales tax (in Hawaii, General Excise Tax). In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or installment payment plan. I accept some credit cards, but these financial considerations are on a case by case basis and solely up to my professional timediscretion. If your account is more than 30 days in arrears and suitable arrangements for payment have not been agreed to, I have the option of using legal means to secure payment, including preparation and transportation costs and timecollection agencies or small claims court, even if which will require me to disclose otherwise confidential information. In most collection situations, the only information I am called to testify by another party. Due to release regarding a client’s treatment is the client’s name, the nature of the services provided, and the amount due. If such legal involvementaction is necessary, my rate for participation its costs will be included in legal activities is $500 per hourthe claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have are available to pay for your treatment. If you have a health insurance benefits policy, it will usually provide some coverage for mental health treatment. I will provide you with whatever reasonable assistance I can in helping you receive facilitating your receipt of the benefits to which you are entitled; however, you (including filling out forms as appropriate. However, you, and not your insurance company) , ultimately are responsible for full payment of my feesthe fee. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limitTherefore, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior coverage booklet that describes mental health services. If you have questions, you should direct these questions to our first meeting so your insurance company. The rising cost of healthcare has resulted in an increasing level of complexity about insurance benefits, which sometimes makes it difficult to determine exactly how much mental health coverage is available. “Managed Health Care Plans” such as HMOs and PPOs often require advance authorization before they will provide reimbursement for mental health services. These plans are often oriented towards a short-term treatment approach designed to resolve specific problems that are interfering with a person’s usual level of functioning. It may be necessary to seek additional approval after a certain number of sessions. In my experience, while quite a lot can be accomplished in short term therapy, many clients feel that more services are necessary after insurance benefits expire. Some managed-care plans may not pay for services to you may fully understand once your benefits as they pertain to our work together. end. If at any point you have questions about your insurance coverage, call your plan administrator. Of coursethis is the case, I will provide you with whatever information I can based on do my experience and best to find another provider who will be happy to help you in understanding the information you receive from continue your insurance companypsychotherapy. You should also be aware that your contract with your health some insurance company requires that I provide it with information relevant agreements may require you to the services that I provide to you. I am required authorize me to provide a clinical diagnosis. Sometimes I am required to provide diagnostic impression, and sometimes additional clinical information such as a treatment plans plan or summariessummary, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requestedtreatment notes. This information will become part of the insurance company files and files, and, in all probability, some or all of it will probably be stored in a computerdigitized. Though all All insurance companies claim to keep such information confidential, but once in their possession, I have no control over what they do with it once it is this information. For example, in their handssome cases, they may share the information with a national medical information data bank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your insurance carrier. CONTACTING ME I am often not immediately available by telephone or e-mail. My communications are limited to my availability during normal business hours, defined as Monday through Friday, 8:00 a.m. to 5:00 p.m., excluding holidays. If you leave me a voicemail or send me an e-mail, I will make every effort to return your call or e-mail as soon as I become available during business hours. I do not usually return cellular text message communications unless they are limited to scheduling. Please understand that contact with me during business hours is dependent upon my availability. If there is an emergency requiring immediate clinical care, you may contact your physician, the 24-hour crisis line (0-000-000-0000), or dial 9-1-1 and ask for help. PROFESSIONAL RECORDS Both law and the standards of my profession require that I keep appropriate treatment records, which include what is called Protected Health Information (PHI). This includes, for example, information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and/or others, or if your clinical records makes reference to another person (other than another health care provider) and I believe that access is reasonably likely to cause substantial harm to such other person, or where information has been supplied to me by others confidentially, you may examine and/or receive a copy of your clinical record if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. I will charge a preparation fee and for certain other expenses related to the request of your file. It will be your responsibility to arrange for a third party, such as a Court reporter or medical copy service, to obtain the records, create a copy, and return the file to me. Your responsibility also includes all financial obligations concerning the third party fees. If I deny your request for access to your records, you have a right of review (except for information provided to me confidentially by others), which I will discuss with you upon your request. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides you with several rights with regard to your clinical record and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Clients under 18 years of age and their parents should be aware that the law allows parents to examine their child’s treatment records unless we have agreed otherwise, or unless I decide that such access is likely to injure the child. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from parents that they give up their access to their child’s records. If they agree, then during treatment I will provide parents only with general information about the progress of the child’s treatment and attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communications will require the child’s assent, unless I feel that the child is in danger or is a danger to someone else. In that case, I will notify the parents of my concerns. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections the child may have. Hawaii State Law has determined that if parents are involved in a custody dispute, the Court shall appoint a Guardian Ad Litem to secure the release of records for the child(ren) involved. LIMITS ON OF CONFIDENTIALITY The law protects In general, the privacy confidentiality of all communications between a client and a psychologistpsychologist is protected by law. In most situations, I can only release information about your treatment to others if you sign a written Authorization authorization form that meets certain legal requirements requirement imposed by HIPAA. There are other situations that require only that you provide written, advanceadvance consent. Your signature on this Agreement provides consent for those activities, as follows:

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. You will be asked to pay at the end of my professional timeeach session. You may pay in cash, including preparation check, or credit card. You will be given a receipt that provides information an insurer would need if you decide to ask for some type of reimbursement from your carrier. If your account has not been paid for more than 60 days and transportation costs and timearrangements for payment have not been agreed upon, even if I am called have the option of using legal means to testify by another partysecure the payment. Due This may involve hiring a collection agency or going through small claims court which will require 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 nature of services provided, and the amount due. If such legal involvementaction is necessary, my rate for participation its costs will be included in legal activities is $500 per hourthe claim. By signing this agreement, you authorize me to employ the services of an outside collection agent or attorney to seek payment of all unpaid fees. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your Also, please note that I am not on any insurance company prior to our first meeting so panels. I will provide you with a receipt at time of payment that you may fully understand use to request reimbursement from your benefits as they pertain to our work togetherinsurance carrier. You should carefully read the section in your insurance coverage booklet that describes mental health services. If at any point you have questions about your insurance 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 patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that 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 Recordclinical record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects By signing this agreement, you authorize me to provide your health insurance company with all information requested of me pertaining to the privacy services I provide to you or your family member. Xxxx XxXxxxxxxx, Ph.D. is an employee of Children’s Health/Children’s Medical Center. As part of his employment at Children’s, he cannot see individuals who are currently receiving medical or psychiatric care at any of Children’s Health/Children’s Medical Center locations (Plano, Southlake or Dallas), or have received care in the past six months at Children’s. Your signature confirms that your child is not currently receiving medical or psychiatric care at Children’s Health/Children’s Medical Center or has received care in the past six months. Once we have all communications between a client and a psychologist. In most situations, I can only release of the information about your treatment insurance coverage, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide writtenalways have the right to pay for my services yourself to avoid the problems described above. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ABIDE BY ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP. IN ADDITION, advanceYOUR SIGNATURE ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE AND ARE AGREEING TO CONDITIONS SET FORTH IN THE SAFE HARBOR AGREEMENT PORTION OF THIS AGREEMENT. SIGNED _____________________________ ____________________ Parent Date _____________________________ _____________________ Parent Date _____________________________ _____________________ Xxxxxx XxXxxxxxxx, Ph.D. Date

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless agreed to otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, Vista Psychological & Counseling Centre, LLC, has the option of my professional timeusing legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require the clinician to disclose otherwise confidential information. In most collection situations, including preparation and transportation costs and timethe only information that the clinician will release regarding a client’s treatment is his/her name, even if I am called to testify by another party. Due to the nature of legal involvementservices provided, my rate for participation in legal activities is $500 per hourdates of service, and the amount due. INSURANCE REIMBURSEMENT REIMBURSEMENT: In order for us Vista Psychological & Counseling Centre, LLC, to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I Vista Psychological & Counseling Centre, LLC, will fill out forms and provide you with whatever reasonable assistance I we can in helping you receive the benefits to which you are entitled; however. However, you (not your insurance company) are responsible for full payment of my the clinician’s fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and Vista Psychological & Counseling Centre, LLC, will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, Vista will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require 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 psychotherapy/counseling after a certain number of sessions. While much can be accomplished in short term psychotherapy/counseling, some clients feel that they need more service after insurance benefits end. Some managed‐care plans will not allow the clinician to provide services to you once your benefits end. If this is the case, the clinician will do their best of find another provider who will help you continue your psychotherapy/counseling. You should also be aware that your contract with your health insurance company requires that I the clinician provide it with information relevant to the services that I provide provided to you. I am The clinician is required to provide a clinical diagnosis. Sometimes I am the clinician is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Recordclinical record. In such situations, I the clinician will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have the clinician has no control over what they do with it once it is in their hands. I In some cases, they may share the information with a national medical information databank. The clinician will provide you with a copy of any report I they submit, if you request it. By signing this Agreement, you agree that I the clinician can provide requested information to your insurance carrier. LIMITS ON CONFIDENTIALITY The law protects Once Vista Psychological & Counseling Centre, LLC, has all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, it will be possible to others discuss what can be accomplished with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide writtenalways have the right to pay for the clinician’s services to avoid the potential problems described above. Under changes to HIPAA in 2009, advanceyou now have the right to elect not to use insurance when seeing a therapist and then no information will be disclosed to your insurance company. You should be aware, however, that you have to make such an election prior to each therapy session and you must pay for those services at that time. You will be charged allowable fees under such circumstances.

Billing and Payments. Your health insurance may cover all You are expected to pay in-full for each session at the time it is held or part prior to the group sessions, unless otherwise agreed upon in writing, or if using In-Network insurance, in which case you will be responsible for any known copay and coinsurance at the time of service. For accounts that have a balance, bills are sent at the fees end of each month for that month, using an electronic billing service. If your account has not been paid for more than 90 days and I will work with you to facilitate the exchange of information with your insurance company arrangements for payment. Howeverpayment have not been agreed upon, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services may be charged an interest rate of up to 2% per month, at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with month, on the real amount of our fee agreementremaining balance. Please also note there that bounced checks will be require a $35 service 30 fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due amount. Center for Valued Living, PLLC has the option of using legal means to mesecure the overdue payment. I also charge $290 per hour for other professional This may involve hiring a collection agency or going through small claims court, which will require me to legally disclose otherwise confidential information. In most collection situations, the only information released regarding a patient’s treatment is his/her name, the nature of services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation servicesprovided, and the time spent performing any other service you may request of meamount due. If you become involved in such collection and/or legal proceedings that require my participationaction are necessary, you will be expected to pay responsible for all the full amount of my professional time, including preparation and transportation these costs and time, even if I am called to testify by another party. Due to these costs will be included in the nature of legal involvement, my rate for participation in legal activities is $500 per hourclaim. INSURANCE REIMBURSEMENT In order Currently, the Center for us Valued Living, PLLC accepts payment directly from select insurance companies. Please inquire with your insurance company if we are an In-Network provider with your specific plan. You may choose to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health use Out-of-Network insurance policy, it will usually provide some coverage for services if your insurance benefits include Out-of-Network mental health treatmentcoverage. I will provide Although you with whatever reasonable assistance I can in helping you receive the benefits may elect to which you are entitled; howeveruse Out-of-Network insurance coverage, you please be aware that YOU (not your insurance company) are responsible for full payment of my fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurerfees at the time of service. If you chose to use insurance, I can provide a detailed receipt for you to submit to your insurer does impose insurance company as a session limit on what they will reimburse and complementary service. If you would like to keep track of where you are within that limithave health insurance, it is your responsibility to contact the insurer to inquirewill usually provide some coverage for mental health treatment and may or may not include group treatment, specifically. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised covers through Out-of- Network benefits, the process you need to contact follow to obtain those benefits and the amount of your deductibles or other obligations BEFORE you begin treatment, or whenever your insurance company prior and/or policy changes. It is your responsibility to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance coverage, call your plan administrator. Of course, I will provide you with whatever find out this information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance companybefore beginning treatment. 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advanceask:

Billing and Payments. Your You will be expected to pay the insurance co-payment for your sessions at the end of each month if you have health insurance may cover all that is involved in the coverage of these services. If this is the case, there will be a statement at the bottom of your bill that reads, "Amount Owed out of Pocket." Pay only this amount and the balance will be paid by your insurance carrier. If you do not have health insurance, or part of the fees and I will work with you to facilitate the exchange of information am not a participating provider with your insurance company for payment. Howevercarrier, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, then you will be expected to pay in full for all each session at the end of my each month. Payment schedules for other professional time, including preparation and transportation costs and time, even if I am called services will be agreed to testify by another party. Due to the nature of legal involvement, my rate for participation in legal activities is $500 per hourwhen they are requested. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your Please note that I am a participating provider with only a limited number of insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance 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 carriers in understanding the information you receive from your insurance companycentral Ohio area. 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 Recordclinical record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects Once we have all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide written, advancealways have the right to pay for my services yourself to avoid the problems described above. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREETOITSTERMSANDALSOSERVESASANACKNOWLEDGEMENTTHATYOU HAVE RECEIVED THE HJPAA NOTICE FORM DESCRIBED ABOVE.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time of my service. Payment for other professional timeservices will be billed to you or charged to your credit card account with written authorization. If your account has not been paid for more than 60 days, including preparation and transportation costs and timethe Practice has the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require the Practice to disclose otherwise confidential information. In most collection situations, even if I am called to testify by another party. Due to the only information released regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal involvementaction is necessary, my rate for participation your signature below indicates agreement to pay such additional collection costs, charges, and expenses including but not limited to court costs, private process server fees, investigative fees, or other costs incurred in legal activities is $500 per hourcollection and reasonable attorney’s fees which are to be calculated as 25% of the entire balance due and owing. INSURANCE REIMBURSEMENT In order The practice does not participate with any insurance plans or panels. You are responsible for us to set realistic treatment goals researching your health insurance and priorities, it filing for reimbursement. 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 The Practice will provide you with whatever reasonable assistance I can in helping you receive the benefits a detailed bill of services to which you are entitled; however, you (not be attached to your insurance company) forms for reimbursement. I will complete forms provided by you when they are responsible necessary for full payment of my feesyou to receive reimbursement from your carrier. This includes, but is not limited to, full responsibility for all sessions You should carefully read the section in your insurance coverage booklet that exceed any session limits imposed by your insurerdescribes mental health services. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance 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. You should also be aware that your contract with your health insurance company requires might require that I provide it with information relevant to the services that I provide provided to you. Maryland permits me to send some information without your consent in order to file appropriate claims. I am required to provide them with a clinical diagnosis. Sometimes I am may be required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information Maryland law prevents insurers from making unreasonable demands for information, but there are no specific guidelines about what unreasonable includes. If I believe that your health insurance company is requesting an unreasonable amount of information, I will call it to your attention and we can discuss what to do. You can instruct me not to send requested information, but this could result in claims not being paid and an additional financial burden being placed on you. Once the insurance company has this information, it 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 have the Practice has no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submitsubmitted, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of my professional timeunusual financial hardship, including preparation you may discuss payment arrangements with your clinician. If your account has not been paid for more than 60 days and transportation costs and timearrangements for payment have not been agreed upon, even if I am called we have the option of using legal means to testify by another partysecure the payment. Due This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information RSA will release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal involvementaction is necessary, my rate for participation its costs will be included in legal activities is $500 per hourthe claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I RSA will fill out forms and provide you with whatever reasonable assistance I we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my our fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I we will provide you with whatever information I we can based on my our experience and will be happy to help you in understanding the information you receive from your insurance company. 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 patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow us to provide services to you once your benefits end. If this is the case, we will do our 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 RSA provide it with information relevant to the services that I provide provided to you. I am Clinicians are required to provide a clinical diagnosis. Sometimes I am we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I RSA will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have RSA has no control over what they do with it once it is in their hands. I In some cases, they may share the information with a national medical information databank. Your clinician will provide you with a copy of any report I submithe or she submits, if you request it. By signing this Agreement, you agree that I RSA and your clinician can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects Once we have all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide writtenalways have the right to pay for my services yourself to avoid the problems described above, advanceunless prohibited by contract.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of my professional timeunusual financial hardship, including preparation I may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 90 days and transportation costs and timearrangements for payment have not been agreed upon, even if I am called have the option of using legal means to testify by another partysecure the payment. Due This may involve hiring a collection agency or going through small claims court 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 involvementaction is necessary, my rate for participation costs will be included in legal activities is $500 the claim. Any account past due by 90 days may also be subject to interest charges of 1.50% per hourmonth. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what the resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever reasonable assistance I can in helping you receive the benefits to which you are entitled; however, you (you, not your insurance company) , are responsible for full payment of my fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance the coverage, call your plan administrator. Of courseDue to the rising costs of health care, I will 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 you reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with whatever information I 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 based on my experience and will be happy to help you accomplished in understanding the information you receive from your short-term therapy, some clients feel that they need more services after insurance companybenefits end. You should also be aware that your contract with your health insurance company requires that I provide it them with information relevant to the services that I provide to provided 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects Once we have all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide writtenhave the right to pay for my services yourself to avoid the problems described above, advanceunless prohibited by contract. Rev. 02/20

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all services at the beginning of my professional timeeach session, including preparation unless you are an EAP referral or your insurance carrier requires another arrangement. Please discuss this with me before your first session. • In circumstances of temporary unusual financial hardship, I may be willing to negotiate a short-term fee adjustment. I can also give you referrals for practitioners or agencies that provide sliding scale payments. • If your account has not been paid for more than 60 days and transportation costs and timearrangements for payment have not been agreed upon, even if I am called have the option of using legal means to testify by another partysecure the payment. Due This may involve hiring a collection agency or going through small claims court 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 involvementaction is necessary, my rate for participation related costs will be included in legal activities is $500 per hourthe claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. If I am an out-of-network provider, your plan may include deductible and higher co-pay than if I am an in-network provider. I will bill your insurance company, unless we agree otherwise, and provide you with whatever reasonable assistance I can in helping you receive the benefits to which you are entitled; howeveran invoice of our sessions, you (however you, not your insurance company) , are responsible for full payment of my fees. This includesYou may pay by cash, but is not limited tocheck, or credit card. However, if your check bounces, you will be responsible for paying the fee that my bank charges me as well as the full responsibility for all sessions that exceed any session limits imposed by your insureramount. If your insurer does impose a session limit on what they Thereafter I will reimburse no longer accept checks from you and you would like must pay in cash or by credit card. I will contact your insurance company or EAP provider to keep track of where you are within that limitverify your mental health benefits. Since mental health benefits may differ from medical benefits, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I will 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 you reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work on specific problems that interfere 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 companya person’s usual level of functioning. You should also be aware that your contract with your health insurance company requires might require 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, except for therapy Notes. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computertheir computer system. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects Once we have all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment authorized services, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above, unless prohibited by your contract. You may also elect to pay my fees if you sign a written Authorization form that meets certain legal requirements imposed decide to continue services even though denied by HIPAA. There are other situations that require only that you provide writtenyour insurance company or EAP provider, advanceunless prohibited by your contract.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held as you do any doctor appointment, unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. I do not do payment plans. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of my professional timeusing legal means to secure the payment. This may involve hiring a collection agency or going to court which will require us to release otherwise confidential information. By engaging in therapy services you agree to pay the fee charged as a legal and lawful debt and agree to pay said fee, including preparation any/all collection agency fees, (33.33%), attorney fees and/or court costs, if such be necessary. You waive now and transportation costs forever the right of exemption under the laws of the constitution of the State of Mississippi and timeany other State. In most collection situations, even if I am called to testify by another party. Due to the only information we release regarding patient’s treatment is his/her name, the nature of legal involvementservices provided, my rate for participation in legal activities is $500 per hourand the amount due. INSURANCE REIMBURSEMENT I will bill your insurance provider following our sessions. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I We will fill out forms and provide you with whatever reasonable assistance I we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my our fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. This is up to the client to find out what their insurance covers, not the therapist. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you describes mental health services. It may fully understand your benefits as they pertain to our work together. differ from physical health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of courseSome 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 patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will provide you with whatever information I can based on my experience and do our best to find another provider who will be happy to help you in understanding the information you receive from continue your insurance companytherapy. You should also be aware that your contract with your health insurance company requires that I you authorize me to provide it with information relevant to the services that I provide to you. If you are seeking reimbursement for services under your health insurance policy, you will be required to sign an authorization form that allows me to provide such information. 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects Once we have all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide writteninsurance coverage, advancewe will discuss what we can expect to

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless agreed to otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not bee paid for more than 60 days and arrangements for payment have not been agreed upon, Vista Psychological & Counseling Centre, LLC has the option of my professional timeusing legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require the clinician to disclose otherwise confidential information. In most collection situations, including preparation and transportation costs and timethe only information that the clinician will release regarding a client’s treatment is his/her name, even if I am called to testify by another party. Due to the nature of legal involvementservices provided, my rate for participation in legal activities is $500 per hourdates of service, and the amount due. INSURANCE REIMBURSEMENT In order for us Vista Psychological & Counseling Centre, LLC, to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I Vista Psychological & Counseling Centre, LLC, will fill out forms and provide you with whatever reasonable assistance I it can in helping you receive the benefits to which you are entitled; however. However, you (not your insurance company) are responsible for full payment of my the clinician’s fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and Vista Psychological & Counseling Centre, LLC, will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, Vista will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require 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 psychotherapy/counseling after a certain number of sessions. While much can be accomplished in short term psychotherapy/counseling, some clients feel that they need more service after insurance benefits end. Some managed-care plans will not allow the clinician to provide services to you once your benefits end. If this is the case, the clinician will do their best of find another provider who will help you continue your psychotherapy/counseling. You should also be aware that your contract with your health insurance company requires that I the clinician provide it with information relevant to the services that I provide provided to you. I am The clinician is required to provide a clinical diagnosis. Sometimes I am the clinician is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Recordclinical record. In such situations, I the clinician will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no the clinician has not control over what they do with it once it is in their hands. I In some cases, they may share the information with a national medical information databank. The clinician will provide you with a copy of any report I they submit, if you request it. By signing this Agreement, you agree that I the clinician can provide requested information to your insurance carrier. LIMITS ON CONFIDENTIALITY The law protects Once Vista Psychological & Counseling Centre, LLC has all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, it will be possible to others discuss what can be accomplished with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide written, advancealways have the right to pay for the clinician’s services to avoid the potential problems described above. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS. YOUR SIGNATURE ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPPA NOTICE FORM DESCRIBED ABOVE. Client or Guardian Signature Date Relationship to Client

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise or unless you have insurance coverage, which requires another arrangement. Please see our fee schedule, below. Fee Schedule: Individual, couples or family session $150.00 Group therapy sessions $45.00 Telephone sessions (per 15 minute increments) $30.00 Correspondence (per 15 minute increments) $30.00 Psychological evaluations and testing (per hour) $175.00 Forensic work and court appearances (per hour) $175.00 Substance Abuse Evaluation (per hour) $150.00 Returned Check Fee $25.00 It is often necessary when seeing children in psychotherapy for the clinician to spend time outside of my professional the session working on the case. Insurance typically only covers face to face therapy and therefore such outside of the session time is billed directly to parents. I will notify you when these circumstances arise. Additional fees will be billed for the following types of situations: communicating with your child's guidance counseler or teacher, reading previous evaluations or reports, revising 504 plans or IEPs, attending school meetings, scoring assessment measures or other diagnostic evaluations. Fee is $30 for 15 minute increments of time. If your account is more than 60 days in arrears and suitable arrangements for payment have not been agreed to, I have the option of using legal means to secure payment, including preparation and transportation collection agencies or small claims court. If such legal action is necessary, the costs and timeof bringing that proceeding will be included in the claim. In most cases, even if the only information, which I am called would release to testify by another party. Due to a court or collection agency, would be the client’s name, the nature of legal involvement, my rate for participation in legal activities is $500 per hourthe services provided and the amount due. INSURANCE REIMBURSEMENT Insurance Reimbursement In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have are available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will provide you with whatever reasonable assistance I can in helping you receive facilitating your receipt of the benefits to which you are entitled; however, you (including filling out forms as appropriate. However, you, and not your insurance company) , are responsible for full payment of my feesthe fee. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limitTherefore, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance coveragequestions, you should call your plan administratoradministrator and inquire. Of course, I will provide you with whatever information I can based on my experience and will be happy to help try to assist you in understanding deciphering the information you receive from your insurance companycarrier. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant If necessary to the services that I provide to you. resolve confusion, I am required willing to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of call the carrier on your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advancebehalf.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. Returned checks will be assessed a $25 administrative fee for each occurrence. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of my professional timeusing legal means to secure the payment unless otherwise prohibited by your insurance carrier. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, including preparation and transportation costs and timethe only information I release regarding a patient’s treatment is his/her name, even if I am called to testify by another party. Due to the nature of services provided, and the amount due. (If such legal involvementaction is necessary, my rate for participation its costs will be included in legal activities is $500 per hour. the claim.) INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. If I am an in-network provider for your insurance carrier, I will bill in accordance with their policy less any applicable co-payments. If we are not an in-network provider for your insurance carrier, I will not fill out forms nor will I submit your requests to your insurance company unless agreed upon at the initiation of services. I will provide you with whatever reasonable assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my the fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to 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 patients feel that they need more services after insurance benefits end. 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects Once I have all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, I will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide written, advancealways have the right to pay for our services yourself to avoid the problems described above (unless prohibited by contract).

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of my professional timeunusual financial hardship, including preparation and transportation costs and time, even if I am called may be willing to testify by another party. Due to the nature of legal involvement, my rate for participation in legal activities is $500 per hournegotiate a fee adjustment or payment installment plan. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it It is important to evaluate what resources remember that you always have available the right to pay for your treatmentmy services yourself to avoid the problems described below. 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 reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance the coverage, call your plan administrator. Of courseIt 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 ben fits 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 provide you with whatever information I can based on do my experience and best to find another provider who will be happy to help you in understanding the information you receive from continue your insurance companypsychotherapy. You should also be aware that your contract with your health insurance company requires that I you authorize me to provide it with information relevant to the services that I provide to you. If you are seeking reimbursement for services under your health insurance policy, you will be required to sign an authorization form that allows me to provide such information. I am required to provide a clinical diagnosis. Sometimes Sometimes, I am required will be requested to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. This may require an additional authorization. (If you refuse such authorization, the insurance company can deny your claims and you will be responsible for paying for services yourself.) In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only Your signature below indicates that you provide written, advancehave read the information in this document and agree to abide by its terms during our professional relationship. Signature of Client/Guardian/Representative Date Signed

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all any fees that you owe at the time of my professional timethe appointment unless we agree otherwise, including preparation or unless your insurance company requires a different arrangement. If you have some extenuating financial hardships, I may be willing to discuss a fee adjustment or payment plan. I accept cash, personal checks and transportation costs and timecertain credit cards. If your check is returned because of insufficient funds/closed account, even if I am called or another reason, you will be billed an additional fee to testify by another party. Due cover bank charges that incur due to the returned check. All accounts should be paid within 30 days unless arrangements have been made, and I reserve the option of using legal means to secure payment. This may involve hiring a collection agency, or going through small claims court, which may require me to disclose otherwise confidential information. In most situations, the only information released is the patient’s name/name of responsible party, nature of services provided, and amount due. (If such legal involvementaction is necessary, my rate for participation the costs will be included in legal activities is $500 per hourthe claim and you are responsible to pay these fees). INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and prioritiesgoals, 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 that has some coverage for mental health treatment. coverage, I will provide you with whatever reasonable assistance I can in helping help you receive the benefits to which you are entitled; however. However, you (not your insurance company) are responsible for full payment of my fees. This includesIT IS CRITICAL THAT YOU CONTACT YOUR INSURANCE COMPANY TO UNDERSTAND EXACTLY WHAT YOUR POLICY COVERS. If, but is not limited toafter reading your insurance coverage information, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose and speaking with a session limit on what they will reimburse and you would like to keep track of where customer service representative, you are within that limitstill uncertain, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance coverageI, call your plan administrator. Of courseor a member of my staff, I will provide you with whatever information I can based on my experience and will be happy to clarify your coverage on your behalf. Insurance benefits have become increasingly more complex. Certain plans require authorization before sessions begin and before the company will reimburse for services. These plans may also be limited to short-term treatment approaches, and often they will not permit more sessions after a certain number of sessions. While much can be accomplished in short- term therapy, individuals often feel that they want more services after their insurance benefits end. Certain plans do not permit me to continue to see you once your benefits end, and in this case, I will help you in understanding the information you receive from your insurance companyfind another provider, if needed. 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 One of the requirements is a clinical diagnosisClinical Diagnosis. Sometimes I am required to provide They may also require additional clinical information Clinical Information, such as treatment plans or summaries, or copies in some cases a copy of your entire Clinical Recordrecord. In such situationscases, I will make every effort attempt to release only the minimum information about you that is necessary for the purpose requestednecessary. This information will become is then part of the insurance company files file, and will probably be stored in a computer. Though all insurance though the companies claim to keep such information confidential, I have no control over what how they do manage their records. In some cases, they may share the information with it once it is in their handsa national medical information data bank. I will can provide you with a copy of any report that I submitam required to submit on your behalf, if you request it. By signing this Agreementagreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects I am happy to discuss what we can expect to accomplish once I have all the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment benefits and if there are limitations to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAAthe number of sessions your contract allows. There are other situations that require only It is important to remember that you provide writtenalways have the right to pay for services yourself to avoid the problems described above, advanceunless you are prohibited from doing so by the contract. Patient Name (please print): Date Date Patient Signature

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. Returned checks are subject to a $35 fee. If your account has not been paid for more than 90 days, and suitable arrangements for payment have not been agreed upon, we have the option of my professional timesuspending or discontinuing treatment, including preparation and transportation costs and timeand/or using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court, even if I am called which will require us to testify by another partydisclose otherwise confidential information. Due to In most collection situations, the only information we release regarding a patient’s treatment is his/her name, dates, the nature of services provided, and the amount due. If such legal involvementaction is necessary, my rate for participation its costs will be included in legal activities is $500 per hourthe claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I Warner & Associates, LLC does not participate with any insurance companies. We will provide you with whatever reasonable assistance I can in helping you receive the benefits an invoice to which you are entitled; however, you (not submit to your insurance company) are responsible company or flexible spending account for full payment of my fees. This includesreimbursement, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by according to your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquireindividual health insurance plan benefits. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I we will provide you with whatever information I we can based on my experience our experience, and will be happy to attempt to help you in understanding the information you receive from required by your insurance companycompany for reimbursement. You should also be aware that your contract with your health insurance company requires YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA FORM DESCRIBED ABOVE. _______________________________________________ Client Name _______________________________________________ Client Signature (if 18 or over) _______________________________________________ ___________________ Parent/Guardian Name (if applicable) Date _______________________________________________ Parent/Guardian Signature (if applicable) _______________________________________________ ____________________ Warner & Associates, LLC Staff Name Date _______________________________________________ Warner & Associates, LLC Staff Signature Consent to Treatment I acknowledge that I provide it with have received, have read, and understand the “General Information and Psychological Services Agreement.” I have had my questions answered adequately at this time. I understand that I have the right to ask questions throughout the course of my assessment and/or treatment and may request an outside consultation. I also understand that the mental health provider may offer additional information relevant about specific treatment issues and treatment methods on an as- needed basis during the course of my treatment or evaluation, and that I have the right to consent to or refuse such treatment. I understand that I can expect regular review of treatment to determine whether treatment goals are being met. I agree to be actively involved in the treatment, and in the review process. No promises have been made as to the services results of this treatment or evaluation, or of any procedures utilized within it. I further understand that I provide may stop my treatment or evaluation at any time, but agree to youdiscuss this decision first with my mental health provider. My only obligation, should I decide to stop treatment, is to pay for the services I have already received, and to attend one final session to discuss my reasons and to terminate. I have been informed that I must give 24 hours notice to cancel an appointment, and that I will be charged $80 if I do not cancel or show up for a scheduled session. I am 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree aware that I can provide requested information must authorize the mental health provider in writing to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment my treatment, but that confidentiality can be broken under certain circumstances of danger to others myself or others. I understand that once I release information to insurance companies or any other third party, there is no guarantee that it will remain confidential. My signature signifies my understanding and agreement with these issues, and with the additional information conveyed in this statement. Client Name Date Client Signature (if you sign a written Authorization form that meets certain 18 or over) Patient/Guardian Name (if applicable) Date Patient/Guardian Signature (if applicable) Warner & Associates, LLC Staff Name Date Warner & Associates, LLC Signature Please Print Client ID#: Form completed by: __________________________________________ Relationship to child: Date: ____ Child’s Full Name: M / F Address: __________________________________________________________________________________ City/State: Zip: Age: _______ Date of Birth: ______/ ______/______ Grade in School: __________ GPA: ___________ Ethnic Identification: African American/Black ______ American Indian/Native American ______ Asian-American/Pacific Islander ______ Caucasian/White ______ Latino/Hispanic ______ Biracial/Multiracial ______ Other: ___________________________ PARENT INFORMATION Parental Marital Status: _____ Never Married _____ Separated Widowed _____ Married _____ Divorced Other Is custody being disputed in any legal requirements imposed by HIPAA. There are other situations that require only that you provide writtenaction? Yes No Parents are: _____ Birth parents Xxxxxx parents _____ Adoptive parents Other Who has physical custody? ________________________ Legal custody? ________________________ Mother’s Name: _______________________________ DOB: ______/ ______/______ Age: ___________ Address (if different from above): __________________________________________________________ City/State: , advanceZip: Phone: Home( ) Work( ) ________ Cell(_____)________________

Billing and Payments. Your health insurance I accept cash and credit cards (there is a charge if you use credit card). You will be expected to pay prior to each session unless we agree otherwise. In circumstances of unusual financial hardship, I may cover all or part of the fees and be willing to negotiate a payment installment plan. I will work with you to facilitate the exchange of information with be responsible for billing your insurance company if you choose to 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 your insurance company. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. HoweverThis may involve hiring a collection agency or going through small claims court 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. SESSIONS AND PROFESSIONAL FEES If therapy services are ultimately responsible begun, I typically schedule one 45-60 minute session (one appointment hour for all fees incurred45-53 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 should contact 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 health insurance company or consult 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 for additional information regarding payment arrangements. Each client is responsible for payment for services at each prior to the first session. - 50-55 minute individual If you miss an appointment without notice or couples counseling session: $290* - Late Cancel (within 48 fail to call more than 24 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there in advance, you will be billed $35 service fee 120 for insufficient funds or payments that are not made according to our payment agreementtime. This $35 fee is in In addition to the original payment due to me. weekly appointments, I also charge $290 per hour this amount for other professional services you may need, though I will break down the hourly cost if I we work for periods of less than one hour. Other services include classroom observations, report writing, telephone conversations lasting longer than 5 15 minutes, consultation servicesconsulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs and time, even if I am called to testify by another party. Due to the nature of legal involvement, my rate for participation in legal activities is $500 per hour. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance 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. 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advanceof

Billing and Payments. Your You will be expected to pay the insurance co-payment for your sessions at the end of each month if you have health insurance may cover all that is involved in the coverage of these services. If this is the case, there will be a statement at the bottom of your xxxx that reads, "Amount Owed out of Pocket." Pay only this amount and the balance will be paid by your insurance carrier. If you do not have health insurance, or part of the fees and I will work with you to facilitate the exchange of information am not a participating provider with your insurance company for payment. Howevercarrier, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, then you will be expected to pay in full for all each session at the end of my each month. Payment schedules for other professional time, including preparation and transportation costs and time, even if I am called services will be agreed to testify by another party. Due to the nature of legal involvement, my rate for participation in legal activities is $500 per hourwhen they are requested. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your Please note that I am a participating provider with only a limited number of insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance 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 carriers in understanding the information you receive from your insurance companycentral Ohio area. 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 Recordclinical record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects Once we have all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide written, advancealways have the right to pay for my services yourself to avoid the problems described above. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ TIDS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENTTHAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise or unless you have insurance coverage which requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of my professional timeunusual financial hardship, including preparation I may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and transportation arrangements for payment have not been agreed upon, I have the option of using 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 and timewill be included in the claim. In most collection situations, even if the only information I am called to testify by another party. Due to release regarding a patient’s treatment is his/her name, the nature of legal involvementservices provided, my rate for participation in legal activities is $500 per hourand the amount due. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, course I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to 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 patients feel that they need more services after insurance benefits end. [Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.] You should also be aware that your contract with your health insurance company requires that I you authorize me to provide it with information relevant to the services that I provide to you. If you are seeking reimbursement for services under your health insurance policy, you will be required to sign an authorization form that allows me to provide such information. 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this AgreementOnce we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you agree feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above [unless prohibited by contract]. COMMUNICATIONS I am often not immediately available by telephone. While I am usually in my office between 10 AM and 8 PM, I probably will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by voicemail that I monitor daily. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You must understand the risks of contacting me via unsecure means. I may use email communications, text messaging, and leave voicemails for setting appointment times and for sending invoices. I also may use a cell phone for making phone calls. While I do what I can provide requested information to your carrierensure the confidentiality, these methods of communication may not be entirely confidential. For example, I am limited by the policies of my email carrier as well as yours. While it is generally agreed upon that psychotherapy via phone is inadvisable, there may be times when phone consult is necessary outside of regularly scheduled appointment times. Phone consults for crises are typically billed at the same rate as office treatment, prorated by the quarter-hour. Insurance companies do not typically pay for teletherapy or e-therapy and therefore you will be fully financially responsible for the charge. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA and/or Illinois law. However, in the following situations, no authorization is required: • I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice with other mental health professionals and that I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. • I also have contracts with a billing software company and a certified public accountant. As required by HIPAA, I have a formal business associate contract with this/these business(es), in which it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the names of these organizations and/or a blank copy of this contract. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot disclose any information without a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If you file a worker’s compensation claim, and I rendering treatment or services in accordance with the provisions of Illinois Workers’ Compensation law, I must, upon appropriate request, provide a copy of your record to your employer or his/her appropriate designee. There are other some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice. ▪ If I have reasonable cause to believe that require only a child under 18 known to me in my professional capacity may be an abused child or a neglected child, the law requires that I file a report with the local office of the Department of Children and Family Services. Once such a report is filed, I may be required to provide additional information. ▪ If I have reason to believe that an adult over the age of 60 living in a domestic situation has been abused or neglected in the preceding 12 months, the law requires that I file a report with the agency designated to receive such reports by the Department of Aging. Once such a report is filed, I may be required to provide additional information. ▪ If you have made a specific threat or violence against another or if I believe that you present a clear, imminent risk of serious physical harm to another, I may be required disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization your hospitalization. ▪ If I believe that you present a clear, imminent risk of serious physical or mental injury or death to yourself, I may be required to disclose information in order to take protective actions. These actions may include seeking your hospitalization or contacting family members or others who can assist in protecting you. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. You may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. [I am sometimes willing to conduct this review meeting without charge.] In most circumstances, I am allowed to charge a copying fee of $26.38 (base charge), $0.99 per pages 1-25, $0.66 for pages 26-50, and for pages in excess of 50 at $0.33 per page (and for certain other expenses) as required under 735 ILCS 5/8-2006. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 12 years of age and their parents should be aware that the law allows parents to examine their child’s treatment records. Parents of children between 12 and 18 cannot examine their child’s records unless the child consents and unless I find that there are no compelling reasons for denying the access. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. Since parental involvement is often crucial to successful treatment, in most cases, I require that patients between 12 and 17 years of age and their parents enter into an agreement that allows parents access to certain additional treatment information. If everyone agrees, during treatment, I will provide writtenparents with general information about the progress of their child’s treatment, advanceand his/her attendance at scheduled sessions. I will also provide parents with a summary of treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. [In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan.] If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require 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 nature of services provided, and the amount due. [If such legal action is necessary, its costs will be included in the claim.]Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. [If the Agreement and Notice are given to patients at the end of the first session and patient is only required to sign the Acknowledgement at the end of the first session, leaving the Agreement to be signed at the beginning of the second session] or YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. [If Agreement is sought before treatment or evaluation begins] Signature of Patient Date Signature of Legal Guardian Date

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - *50-55 minute individual or counseling session: $240 (Longer sessions billed at a commensurate rate) *55 minute couples counseling session: $290* - 240 *Late Cancel (within 48 hours for any reason) or No Show: $290* - 240 *90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. 65 Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 240 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs and time, even if I am called to testify by another party. Due to the nature of legal involvement, my rate for participation in legal activities is $500 350 per hour. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance 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. 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advanceadvance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If a client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning the professional services that I provided you, such information is protected by the psychologist-client privilege law. I cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. There are some situations in which I am legally obligated to take actions that I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. • If I have reasonable cause to believe that any child or dependent adult with whom you may have contact or knowledge of has been abused, I am required to file a report with the appropriate government agency. Once such a report is filed, I may be required to provide additional information. • if you threatened violence, I must protect the other person(s) and you by possibly disclosing information about your threat to the appropriate persons and authorities • if you become mentally ill and become unable to take care of your basic needs or become a danger to yourself or others and also refuse treatment, I must report your condition to the authorities • if you provide me with information that another health care provider is not able to practice with reasonable skill and safety due to a mental or physical condition • If a client communicates an imminent threat of serious physical harm to him/herself, I may be required to disclose information in order to take protective actions. These actions may include initiating hospitalization or contacting family members or others who can assist in providing protection. • if you tell me that you are suffering from an infectious disease, such as HIV, I must report your identity to the local health care officer. • under certain select circumstances the court may order your treatment records be released to another party involved in litigation with you If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to me confidentially by others, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. If I refuse your request for access to your records, you have a right to of review, which I will discuss with you upon request. PATIENT RIGHTS HIPAA provides you with several rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Clients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. Even where parental consent is given, children over age 12 may have the right to control access to their treatment records. While privacy in psychotherapy is very important, particularly with teenagers, parental involvement is also essential to successful treatment, particularly with younger children. For children age 12 and over, I request an agreement between my client and his/her parents allowing me to share general information about the progress of the child’s treatment and his/her attendance at scheduled sessions. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. Statement of Agreement Regarding Fees and Services - Consent: Your signature below indicates that you have read the Notice of Privacy Practices and the information included in this document and agree to abide by this document’s stipulations during our professional relationship. I have read Xx. Xxxxxxxx'x policies and my responsibilities as a client, fee for service, confidentiality, and patient rights. I understand and agree that I will be charged: for any outstanding, unpaid bills; a full session fee for any appointments that I miss for any reason with less than 48 hours notice; and, if I am a member of a couple, for any sessions missed by one or both members of the couple. I have had the opportunity to ask questions and discuss them, and give my informed consent for services. If requested, I have received a copy of this agreement. I agree to abide by the terms therein. Client Name (Printed) Client Signature Date Client Name (Printed)

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless agreed to otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for in more than 60 days and arrangements for payment have not been agreed upon, Preferred Care Counseling, LLC has the option of my professional timeusing legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require the clinician to disclose otherwise confidential information. In most collection situations, including preparation and transportation costs and timethe only information that the clinician will release regarding a client’s treatment is his/her name, even if I am called to testify by another party. Due to the nature of legal involvementservices provided, my rate for participation in legal activities is $500 per hourdates of service and the amount due. INSURANCE REIMBURSEMENT In order for us Preferred Care Counseling, LLC, to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I Preferred Care Counseling, LLC will fill out forms and provide you with whatever reasonable assistance I it can in helping you receive the benefits to which you are entitled; however. However, you (not your insurance company) are responsible for full payment of my the clinician’s fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the sections in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and Preferred Care Counseling, LLC will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, Preferred Care 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 difficulty 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 psychotherapy/counseling after a certain number of sessions. While much can be accomplished in short term psychotherapy/counseling, some clients feel that they need more service after insurance benefits end. Some managed-care plans will not allow the clinician to provide services to you once your benefits end. If this is the case, the clinician will do their best to find another provider who will help you continue psychotherapy/counseling. You should also be aware that your contract with your health insurance company requires that I the clinician provide it with information relevant to the services that I provide provided to you. I am The clinician is required to provide a clinical diagnosis. Sometimes I am the clinician is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Recordclinical record. In such situations, I the clinician will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have the clinician has no control over what they do with it once it is in their hands. I In some cases, they may share the information with a national medical information databank. The clinician will provide you with a copy of any report I they submit, if you your request it. By signing this Agreement, you agree that I the clinician can provide requested information to your insurance carrier. LIMITS ON CONFIDENTIALITY The law protects Once Preferred Care Counseling, LLC has all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, it will be possible to others discuss what can be accomplished with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel you are ready to end your sessions. There are other situations that require only It is important to remember that you provide written, advancealways have the right to pay for the clinician’s services to avoid the potential problems described above. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS. YOUR SIGNATURE ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPPA NOTICE FORM DESCRIBED ABOVE. Client or Guardian Signature Date Relationship to Client

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held unless we agree otherwise or unless you have insurance coverage, which requires another arrangement. Payment schedules for other professional services will be agreed to at the time these services are requested. In circumstances of my professional timeunusual financial hardship, I’m willing to negotiate a sliding fee adjustment or installment payment plan. If your account is more than 60 days in arrears and suitable arrangements for payment have not been agreed to, I have the option of using legal means to secure payment, including preparation and transportation collection agencies or small claims court. If such legal action is necessary, the costs and timeof bringing that proceeding will be included in the claim. In most cases, even if the only information, which I am called to testify by another party. Due to release, about a client's treatment would be the client's name, the nature of legal involvementthe services provided, my rate for participation in legal activities is $500 per hourand the amount due. Initial INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have are available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will provide you with whatever reasonable assistance I can in helping you receive facilitating your receipt of the benefits to which you are entitled; howeverentitled including filling out forms as appropriate. However, you (you, and not your insurance company) , are responsible for full payment of my fees. This includesthe fee, but is not limited which we have agreed to, full responsibility for all sessions that exceed any session limits imposed by unless this policy is covered in my contract, if any, with your insurerinsurance company. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limitTherefore, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance coveragequestions, you should call your plan administratoradministrator and inquire. Of course, I will provide you with whatever information I can based on my experience and will be happy to help try to assist you in understanding deciphering the information you receive from your carrier. If necessary to resolve confusion, I am willing to call the carrier on your behalf. The escalation of the cost of health care has resulted in an increasing level of complexity about insurance companybenefits, which sometimes makes it difficult to determine exactly how much mental health coverage is available. Managed Health Care Plans such as HMOs and PPOs often require advance authorization before they will provide reimbursement for mental health services. These plans are often oriented towards a short-term treatment approach designed to resolve specific problems that are interfering with one's usual level of functioning. It may be necessary to seek additional approval after a certain number of sessions. In my experience, quite a lot can be accomplished in short- term therapy, but many clients feel that more services are necessary after insurance benefits expire. You should also be aware that your contract with your health most insurance company requires that I provide it with information relevant agreements require you to the services that I provide to you. I am required authorize me to provide a clinical diagnosis. Sometimes I am required to provide , and sometimes additional clinical information such as a treatment plans plan or summariessummary, or copies in rare cases, a copy of your the entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requestedrecord. This information will become part of the insurance company files and files, and, in all probability, some of it will probably be stored in a computercomputerized. Though all All insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with it once it. In some cases, they may share the information with a national medical information data bank. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself and avoid the complexities, which are described above. Initial for all of the above Insurance coverage for testing: Many insurance plans do not pay for psychological testing or limit the amount of payment; this is especially true for testing which they consider educational. In these cases, testing is considered a "non-covered benefit". There is much confusion about this because many clients are told by their insurance companies that evaluations are covered-this often means a one-hour, face-to-face clinical interview but not testing. If you plan to use insurance for testing it is best to let my office manager check on your coverage for you. We will then let you know, to the best of our knowledge, what portion of the testing your insurance will cover and how much will be your responsibility. Your portion of the testing will be billed at my standard professional fee for "non-covered benefits" plus any co-payment or deductible for your insurance. CONTACTING ME Routine, non-emergency situations: I am often not immediately available by telephone. While I am usually in their handsmy office between 10 AM and 7 PM, I usually will not answer the phone when I am with a client. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it with the exception of weekends and holidays. If you are difficult to reach, please leave some times when you will be available. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist on call. If I will be unavailable for an extended time, I will provide you with the name of a copy of any report I submitcolleague to contact, if you request itnecessary. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advanceInitial

Billing and Payments. Your health insurance may cover all I accept credit cards, debit cards, HSA cards, and FSA cards. No checks or part of the fees cash are accepted. Before scheduling your first session, information for an active credit, debit, HSA, or FSA card is required and I will work with you be truncated and securely stored by a third-party bankcard processor, Pineapple Payments/CardConnect, to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel meet Payment Card Industry (within 48 hours for any reasonPCI) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreementrequirements. Please note there be advised that your card for each session will be $35 service fee for insufficient funds or payments that are not made according to our payment agreementcharged after the session has been held unless we agree otherwise. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour Payment schedules for other professional services you may needwill be agreed to when such services are requested. Any charges will show up on your financial statement (e.g., though credit card statement) as “DC Services”. If payment after a session is not received for any reason, I will break down notify you of this and further sessions will not be scheduled until the hourly cost if balance is paid in full. If your credit, debit, HSA, or FSA card on file has expired, I work require you to replace it with an active card before your next session is scheduled. If your account has not been paid for periods more than 60 days and arrangements for payment have not been agreed upon, I have the option of less than one hourusing legal means to secure the payment. Other This may involve hiring a collection agency or going through small claims court. If this should occur, its 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 dates, times, and nature of services include telephone conversations lasting longer than 5 minutes, consultation servicesprovided, and the amount due. APPOINTMENTS Your scheduled time spent performing any other service you may request of meis reserved for you. If you become involved in legal proceedings that require my participationarrive late, you your session will be expected to pay for all shortened by that amount of my professional time, including preparation time and transportation costs and time, even if I am called to testify by another party. Due to the nature of legal involvement, my rate for participation in legal activities is $500 per hour. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will provide you with whatever reasonable assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are still responsible for paying the full payment session fee. Please try to arrive punctually to get the full benefit of my feesyour session. Telehealth Sessions I might offer telehealth sessions which are sessions conducted by telephone or video. This includes, but is would be charged at the regular rate. Please be aware that the procedure code for telehealth services are different than for an in-office appointment and insurance coverage may not limited to, full responsibility for all sessions that exceed any session limits imposed by be available depending on your insurerparticular plan. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it It is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services clarify this in advance with your insurance policy covers. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance 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. 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session when it is held, unless we agree otherwise, or you have insurance coverage. Insurance co-pays are due at each session. Individual, couple, or family session (45-50 minutes) $150.00 Telephone sessions (per 15 minute increments) 30.00 Correspondence (per 15 minute increments) 30.00 Psychological evaluations and testing (per hour) 175.00 Forensic work and court appearances (per hour) 300.00 Substance Abuse Evaluation (per hour) 150.00 Returned Check Fee 25.00 When treating children, the clinician may spend working time outside of my professional timethe session. Insurance typically covers only face-to-face therapy. Outside-of-session time will be billed directly to parents. Additional fees include: communicating with guidance counselors or teachers, reviewing previous reports, revising 504 plans or IEPs, attending school meetings, and scoring assessments. The fee is $30 for 15-minute increments. I will notify you if any of these charges apply. OVERDUE ACCOUNTS If your account is past 60 days overdue, I have the option of using legal means to secure payment, including preparation and transportation costs and timecollection agencies or small claims court. The cost of proceedings will be included in the claim. In most cases, even if the only information I am called to testify by another party. Due to would release would be the client’s name, the nature of legal involvementthe services provided, my rate for participation in legal activities is $500 per hourand the amount due. INSURANCE REIMBURSEMENT In order for us to AND DEDUCTIBLES To set realistic treatment goals and prioritiesgoals, it is important to evaluate review what payment resources you have are available to pay for your treatment. If It is important you have a health find out exactly what your insurance policypolicy covers, it will usually provide some coverage for mental health treatmentand any deductible the insurance company requires you to pay. Speak to the insurance company or your employer with any questions. I will provide you with whatever reasonable what assistance I can in helping you receive can, including filling out forms or calling the benefits to which you are entitled; howeverinsurance company on your behalf, if necessary. However, you (not your insurance company) are responsible for full payment of my feesthe fee should your insurance company not cover your treatment. This includesSome plans, but is not limited tosuch as HMOs and PPOs, full responsibility require advance authorization for all sessions sessions. They are often oriented toward brief treatment of very specific problems that exceed any session limits imposed by your insurerinterfere with daily functioning. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you A lot can be accomplished in short-term therapy, though many clients feel more services are within that limit, it is your responsibility to contact the insurer to inquirenecessary after insurance benefits expire. It is very important that to discuss what we can accomplish with the benefits available, and what will happen if benefits run out before you find out exactly what mental health services your insurance policy coversfeel ready to end our sessions. You are strongly advised may always pay for my services yourself and avoid any insurance complexities. CONTACTING ME I'm often not immediately available by phone, and your call will reach my voicemail. I will try to contact return your insurance company prior to our first meeting so that you may fully understand your benefits call as they pertain to our work together. soon as possible, with the exception of weekends and holidays. If at any point you have questions about your insurance coverageare difficult to reach, please leave some times when you will be available. If it is urgent, call your my answering service at 603.886.6941, let them know you are in crisis, and have them get in touch with me or one of the other clinicians. If you can't wait for a call back, go to the nearest Emergency Room and have them get in touch with me. If I plan administrator. Of courseto be away from the office for an extended period of time, I will provide you with whatever information I the name of a trusted colleague you can based on my experience and will be happy contact if necessary. MINORS If you are under 18, your parents may have the right to help you in understanding the information you receive from examine your insurance companyrecords. You should also be aware My policy is to request that your contract with your health insurance company requires parents give up that I provide it with information relevant to the services that I provide to youright. 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. In such situationsIf they agree, I will make every effort to release provide them only the minimum with general information about our work together, unless I feel there is a high risk you will seriously harm yourself or another. In that is necessary for the purpose requestedcase I will notify them of my concern. 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 confidentialBefore giving them any information, I have no control over what they do will discuss it with it once it is in their hands. I will provide you with a copy of any report I submityou, if you request itpossible. By signing Under Federal Confidentiality Laws, a child twelve years or older seeking treatment for substance use has the same rights to confidentiality as an adult. Under this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situationslaw, I can only release information about your treatment to others if may not let anyone know you sign attend counseling here or identify you as a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advancesubstance user.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of my professional timeusing legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, including preparation and transportation costs and timethe only information I release regarding a patient's treatment is his/her name, even if I am called to testify by another party. Due to the nature of services provided, and the amount due. If such legal involvementaction is necessary, my rate for participation its costs will be included in legal activities is $500 per hourthe claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes substance abuse and mental health services. If at any point you have questions about your insurance 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. 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 patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects Once we have all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide writtenalways have the right to pay for my services yourself to avoid the problems described above (unless prohibited by contract]. Your signature on the attached sheet indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. INDIANA SUBSTANCE ABUSE PROFESSIONAL CLIENT AGREEEMENT YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE RECEIVED/READ THIS AGREEMENT, advanceHAVE ORALLY REVIEWED IT WITH STAFF AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. NAME DATE

Billing and Payments. Your health Unless we agree otherwise or unless you have insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments coverage that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participationrequires another arrangement, you will be expected to pay for all psychotherapy services within one month of receiving my professional timebill. Alternatively, including preparation and transportation costs and time, even if I am called to testify by another party. Due to the nature of legal involvement, my rate for participation in legal activities is $500 per hour. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available many patients prefer to pay for your treatmentservices at the end of each session. If you have a health insurance policy, it will usually provide some coverage This often simplifies the billing process for mental health treatmentboth parties. At the end of each month I will provide you with whatever reasonable assistance a bill of any outstanding balance on your account. For psychological assessment, 50% of the total is due on the date that testing is initiated, with the remainder due on the date the test results are presented to you. Payment for court appearances and other services that are related to legal proceedings is due in advance of those services. Payment schedules for other professional services will be agreed to when they are requested. Any balance that is 30 days past due (i.e., 30 days past the statement date on which it appears) is subject to a % 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 can reserve the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require 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 nature of services provided, and the amount due. You will be responsible for all court, attorney, and other fees incurred in helping attempts to collect outstanding balances over 60 days past due. If you receive the benefits 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 which you are entitled; however, and you will be responsible for its payment. INSURANCE REIMBURSEMENT You (not your insurance company) are responsible for full payment of my fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised If you wish to contact use your health insurance to seek payment for treatment, I will ask you to fill out an authorization so that I can provide information to your insurance company prior that will allow me to our first meeting so provide the information necessary to secure payment for the services I provide for you. This Authorization will be in effect for one year, but can be revoked at any time. However, if revoked, I will continue to have the right to forward information necessary to process claims for services already provided. You should carefully read the section in your insurance coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will would be happy willing to help assist you in understanding the information you receive from your insurance company. 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. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance.

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. [In circumstances of my professional timeunusual financial hardship, including preparation I may be willing to negotiate a fee adjustment or payment installment plan.] If your account has not been paid for more than 60 days and transportation costs and timearrangements for payment have not been agreed upon, even if I am called have the option of using legal means to testify by another partysecure the payment. Due This may involve hiring a collection agency or going through small claims court 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 involvementaction is necessary, my rate for participation its costs will be included in legal activities is $500 per hour. the claim.] INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance 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 Recordclinical record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects Once we have all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, we will discuss what we can expect to others accomplish with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide written, advancealways have the right to pay for my services yourself to avoid the problems described above [unless prohibited by contract].

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment Payment for services is the patient’s responsibility and due at each sessionthe time of service unless you have insurance coverage that requires another arrangement (see Insurance Reimbursement below). - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour Payment schedules for other professional services you will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may needinvolve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, though the only information I will break down release regarding a patient’s treatment is his/her name, the hourly cost if I work for periods nature of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation servicesprovided, and the time spent performing any other service you may request of meamount due. [If you become involved in such legal proceedings that require my participationaction is necessary, you its costs will be expected included in the claim.] Any balances due in excess of 90 days are subject to pay for all of my professional time, including preparation and transportation costs and time, even if I am called to testify by another party. Due to the nature of legal involvement, my rate for participation in legal activities is $500 per hourinterest being added. INSURANCE REIMBURSEMENT In order for us It is the patient’s responsibility to set realistic treatment goals verify the details of your mental health coverage with your insurance company(ies) and prioritiesto determine if an authorization is required. (Note: Other information you may want to obtain from your insurance company might be: deductible amounts, it reimbursement amounts, if authorization is important to evaluate required, number of visits allowed per benefit year, what resources are the dates of the benefit year, if a referral from your primary care physician or a psychiatrist is required, yearly and lifetime maximum reimbursement amounts, etc. When consulting with your insurance company, advise them that you have available to pay for are requesting out-of-network, mental health information.) You should carefully read the section in your treatmentinsurance coverage booklet that describes mental health services. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will provide you with whatever reasonable 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. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact your insurance company prior to our first meeting so that you may fully understand your benefits as they pertain to our work together. . If at any point you have questions about your insurance 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. Some insurance companies 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 patients feel that they need more services after insurance benefits end. Please be advised that I am an "out-of-network" provider with insurance companies. I will provide you with the completed forms for you to file; 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. Any balances due in excess of 90 days are subject to interest being added. Please discuss the details of secondary or supplemental insurance reimbursement with me or the appropriate business associate that handles this for me. It is your responsibility to advise us if you have a change of address, phone number(s), insurance coverage, and/or place of employment so that we can update our file for account accuracy. PLEASE BRING YOUR INSURANCE CARD TO YOUR FIRST APPOINTMENT. You should also be aware that 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 addi tional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment It is important to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only remember that you provide written, advancealways have the right to pay for my services yourself to avoid the problems described above [unless prohibited by contract].

Billing and Payments. Your health insurance may cover all or part of the fees and I will work with you to facilitate the exchange of information with your insurance company for payment. However, you are ultimately responsible for all fees incurred. You should contact your health insurance company or consult with me for additional information regarding payment arrangements. Each client is responsible for payment for services at each session. - 50-55 minute individual or couples counseling session: $290* - Late Cancel (within 48 hours for any reason) or No Show: $290* - 90-minute group therapy session: $80* * At the beginning of each year I make an inflation adjustment to keep up with the real amount of our fee agreement. Please note there will be $35 service fee for insufficient funds or payments that are not made according to our payment agreement. This $35 fee is in addition to the original payment due to me. I also charge $290 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for each session at the time it is held, unless agreed to otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. Payments for services can be made by cash, check and credit card. We add a 3.5% surcharge on all credit card payments. This surcharge is not greater than our total cost of my professional timeaccepting credit cards. There is no surcharge for debit card payments. We encourage you to take a receipt for all cash transactions in order to best serve you. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, including preparation and transportation costs and timeVista Psychological & Counseling Centre, even if I am called LLC, has the option of using legal means to testify by another partysecure the payment. Due This may involve hiring a collection agency or going through small claims court which will require the clinician to disclose otherwise confidential information. In most collection situations, the only information that the clinician will release regarding a client’s treatment is his/her name, the nature of legal involvementservices provided, my rate for participation in legal activities is $500 per hourdates of service, and the amount due. INSURANCE REIMBURSEMENT REIMBURSEMENT: In order for us Vista Psychological & Counseling Centre, LLC, to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I Vista Psychological & Counseling Centre, LLC, will fill out forms and provide you with whatever reasonable assistance I we can in helping you receive the benefits to which you are entitled; however. However, you (not your insurance company) are responsible for full payment of my the clinician’s fees. This includes, but is not limited to, full responsibility for all sessions that exceed any session limits imposed by your insurer. If your insurer does impose a session limit on what they will reimburse and you would like to keep track of where you are within that limit, it is your responsibility to contact the insurer to inquire. It is very important that you find out exactly what mental health services your insurance policy covers. You are strongly advised to contact should carefully read the section in your insurance company prior to our first meeting so coverage booklet that you may fully understand your benefits as they pertain to our work together. describes mental health services. If at any point you have questions about your insurance the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and Vista Psychological & Counseling Centre, LLC, will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, Vista will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require 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 psychotherapy/counseling after a certain number of sessions. While much can be accomplished in short term psychotherapy/counseling, some clients feel that they need more service after insurance benefits end. Some managed‐care plans will not allow the clinician to provide services to you once your benefits end. If this is the case, the clinician will do their best of find another provider who will help you continue your psychotherapy/counseling. You should also be aware that your contract with your health insurance company requires that I the clinician provide it with information relevant to the services that I provide provided to you. I am The clinician is required to provide a clinical diagnosis. Sometimes I am the clinician is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Recordclinical record. In such situations, I the clinician will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have the clinician has no control over what they do with it once it is in their hands. I In some cases, they may share the information with a national medical information databank. The clinician will provide you with a copy of any report I they submit, if you request it. By signing this Agreement, you agree that I the clinician can provide requested information to your insurance carrier. LIMITS ON CONFIDENTIALITY The law protects Once Vista Psychological & Counseling Centre, LLC, has all of the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment insurance coverage, it will be possible to others discuss what can be accomplished with the benefits that are available and what will happen if they run out before you sign a written Authorization form that meets certain legal requirements imposed by HIPAAfeel ready to end your sessions. There are other situations that require only It is important to remember that you provide writtenalways have the right to pay for the clinician’s services to avoid the potential problems described above. Under changes to HIPAA in 2009, advanceyou now have the right to elect not to use insurance when seeing a therapist and then no information will be disclosed to your insurance company. You should be aware, however, that you have to make such an election prior to each therapy session and you must pay for those services at that time. You will be charged allowable fees under such circumstances. Should you elect to not use your insurance, or the services are not covered by insurance or are out of network with your insurance, you are entitled under the No Surprise Act to receive a good faith estimate. Separate paperwork has been provided pertaining to this 2022 No Surprise Act legislation and is also available on our website xxx.xxxxxxxx.xxx. You also have the option to waive your federal consumer protections when the nature of mental health concerns do not lend themselves to a good faith estimate.