Common use of Billing and Payments Clause in Contracts

Billing and Payments. You will be expected to pay for each session at the time it is held, unless we have agreed otherwise. [In circumstances of financial hardship I may be willing to negotiate a fee adjustment or payment installment plan.] I will accept credit card payment for services. At the time a credit card payment is made, the card must be present. A copy will be made and secured under lock and key. For appointments that are missed or cancelled less that 24 hours in advance you authorize payment for the missed session on you credit card (Initial for agreement of this provision) 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 payment. This may involve hiring a collection agency or going through small claims court. [If such legal action is necessary, tis costs will be included in the claim.] In most collection situations, the only information I will release regarding the patient’s treatment is his/her name, the dates, times and nature of services provided, and the amount. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party. [I charge $500 per hour for professional services I am asked or required to perform in relation to your legal matter. This includes preparation time. I also charge a copying fee of $.50/page for records requested plus a $50 record retrieval fee.] CONTACTING ME I am often not immediately available by telephone. 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 holidays and vacations (scheduled and discussed in advance). Since I am not immediately available, in the case of a true emergency, please call 911 and/or proceed to the nearest emergency room. If I am not available for an extended period of time, I will provide you with the name of a colleague to contact in case you need to consult a psychotherapist urgently.

Billing and Payments. You will be expected to pay for each session your insurance co-pay or full-fee at the time it is held, unless we have agreed otherwiseof service. [In circumstances of financial hardship I may be willing Co-payments and deductibles are established by your insurance company. Please review your insurance mental health benefits prior to negotiate a fee adjustment or payment installment plan.] I will accept credit card payment for services. At the time a credit card payment is made, the card must be present. A copy will be made and secured under lock and key. For appointments that are missed or cancelled less that 24 hours in advance you authorize payment for the missed session on you credit card (Initial for agreement of this provision) 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 payment. This may involve hiring a collection agency or going through small claims court. [If such legal action is necessary, tis costs will be included in the claim.] In most collection situations, the only information I will release regarding the patient’s treatment is his/her name, the dates, times and nature of services provided, and the amountour first meeting. If you become involved have any questions regarding your insurance plan please contact your insurance provider in legal proceedings order to receive the most accurate information regarding your plan. Two billable sessions (which may include a missed session that require my participationwas not cancelled in advance) of which payment is not made will result in postponement of therapeutic services. If payment arrangements are not made within five business days of receiving an invoice, your therapy time slot will not be reserved. I accept payments by check, cash or MC/Visa. Payment schedules for other professional services will be agreed to if/when you request them. If you make a payment by check and your check does not clear due to insufficient funds or any other reason, you will be expected to pay reimburse us in full for any professional time I spend on your legal matter, even if the request comes from another partyrelated bank fees that we are charged as a result. [I charge $500 per hour for professional services I am asked or required to perform in relation to your legal matter. This includes preparation time. I also charge a copying fee of $.50/page for records requested plus a $50 record retrieval fee.] CONTACTING ME I am often not immediately available by telephonephone because I do not answer the phone when I am in sessions with clients. When Calls go to my voicemail when I am unavailable, my telephone is answered by voice mail that which I monitor frequentlycheck regularly during weekdays. I will make every effort to return your call on the same day as soon as possible (usually within a few hours and almost always within 24 hours). If you make it with the exception of holidays and vacations (scheduled and discussed are difficult to reach, please leave times you will be available. If you want me to use discretion when calling you or leaving a message for you, please let me know in advance). Since At times when I am not immediately available, in the case of a true emergency, please call 911 and/or proceed to the nearest emergency room. If I am not available will be unavailable for an extended period of time, I will provide you with the name of a colleague to contact if necessary. If you are in an emergency situation call your local emergency services at 911, or call or go to the nearest hospital emergency room and tell them what is happening. I will get back to you as soon as I possibly can in such situations, but I may not be able to get back to you immediately in all cases. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep treatment records. You are entitled to examine and/or receive a copy of your records if you request it in writing unless I believe that seeing them would be emotionally damaging, in which case you I will send them to a mental health professional of your choice. Because these are professional records, they can be misinterpreted and/ or be upsetting to people who are not mental health professionals. In order to see your records, we will need to consult a psychotherapist urgentlydiscuss the contents together. I reserve the right to charge you for the costs of copying and sending your records if you request them.

Billing and Payments. You will be expected to pay for each session service at the time it is heldprovided, unless we have agreed otherwisemake other prior arrangements. [In circumstances Checks, cash, and credit card payments are acceptable. You may keep your credit card information on file with me so that I can easily charge each service as it is provided. I collect co-pays at the time of financial hardship service. If you are uncertain of your co-pay, please call your insurance company (there is usually a toll-free number on the back of the insurance card). My current fees are $135.00 for the first 50-minute session, and $125.00 for each subsequent 50-minute psychotherapy session. If you are unable to determine your co-pay prior to your first appointment, I may ask that you pay the fees in full until your insurance company responds to the claims. Once your usual co-pay amount can be willing to negotiate a fee adjustment or payment installment plan.] determined from claims paid by your insurance company, I will accept credit card payment for servicesbe happy to either issue you a refund (if you request it) or I will stop collecting co-pays until you exhaust your credit. At the time a credit card payment is made, the card must be presentUnpaid balances should never accrue. A copy will be made and secured under lock and key. For appointments that are missed or cancelled less that 24 hours in advance you authorize payment for the missed session on you credit card (Initial for agreement of this provision) If your account has not been paid for more than 60 90 days and arrangements for payment have not been agreed upon, I have the 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. [If such legal action is necessaryINSURANCE REIMBURSEMENT You (not your insurance company) are responsible for full payment of my fees. Insurance companies often take 4-6 weeks to process a claim, tis costs so expect a delay. You will be included in the claim.] In most collection situations, the only information typically receive an explanation of your benefits before I will release regarding the patient’s treatment is his/her name, the dates, times receive payment. I suggest you keep a log of your sessions and nature of services provided, and the amountyour payments to me. If you become involved have a restriction on the number of visits, I suggest you keep track of the number of visits we have. If I am not a provider for your specific insurance company, I will not be considered an “in legal proceedings that require my participationnetwork” provider. If you have a health insurance policy, it will usually provide some coverage for mental health treatment, and it might do so by considering me an “out of network” provider. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled, if you choose to submit claims after you have paid me in full for the service(s) I provide. Payment is always due at or before the time of service. If you wish to file claims with an insurance provider, you will should be expected aware that your contract with your health insurance company requires that I provide information relevant to pay for any professional time those services. For example, I spend on your legal matter, even if the request comes from another party. [I charge $500 per hour for professional services I am asked or would be required to perform provide a clinical diagnosis in relation order for you to your legal matterfile claims and I might be required to provide additional clinical information such as treatment plans or summaries. This includes preparation time. I also charge a copying fee of $.50/page for records requested plus a $50 record retrieval fee.] CONTACTING ME I am often not immediately available by telephone. When I am unavailableIn such situations, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on release only the same day minimum information about you make it with that is necessary for the exception purpose requested. This information will become part of holidays the insurance company files and vacations (scheduled and discussed will probably be stored in advance)a computer. Since I am not immediately available, in the case of a true emergency, please call 911 and/or proceed Though all insurance companies claim to the nearest emergency room. If I am not available for an extended period of timekeep such information confidential, I will have no control over what they do with this information once it is in their hands. By signing this Agreement, you agree that I can provide you with requested information to your insurance company. You always have the name of a colleague right to contact in case you need to consult a psychotherapist urgentlypay for services yourself, and can avoid the problems described above by not filing for reimbursement.

Billing and Payments. You will be expected to pay for each session Payment is collected via cash, personal check or credit card at the time it is held, unless we have agreed otherwiseend of each session. [In circumstances of financial hardship I may be willing to negotiate a fee adjustment or payment installment plan.] I will accept credit card payment for services. At the time a credit card payment is made, the card must be present. A copy will be made and secured under lock and key. For appointments that are missed or cancelled less that 24 hours in advance you authorize payment for the missed session on you credit card (Initial for agreement of this provision) 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. [If (In such legal action is necessary, tis costs will be included in the claim.] In most collection situationsa situation, the only information I used will release regarding the patient’s treatment is his/her be client name, the dates, times and nature of services providedand amount due) INSURANCE REIMBURSEMENT I am not currently listed on any insurance panels, which means that I am not “in-network” for any medical insurance provider. As a licensed professional clinical counselor, I am not able to bill Medicare. I will give you a receipt and you are welcome to apply for reimbursement of the amountfee through your medical insurance provider. I cannot guarantee that your insurance provider will cover this expense, so please consult with your provider prior to starting services. If you become involved do submit a receipt to your insurance company for reimbursement, I may be contacted to provide clinical information. I may need to provide a clinical diagnosis, treatment plans or summaries or in rare cases, copies of the entire record. Though all insurance companies claim to keep this information confidential, there is no guarantee of confidentiality. PROFESSIONAL RECORDS The laws and standards of our profession require that I keep treatment records. You are entitled to receive a copy of your records or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting. If you wish to see your records, I recommend that your review them in our presence. These records are stored in a locked file cabinet. CONFIDENTIALITY In general, the privacy of all communications between a client and a counselor is protected by law, and I can only release information about our work to others with your written permission. But there are a few exceptions (described below). In most legal proceedings that require my participationproceedings, you will be expected have the right to pay for prevent me from providing any professional time information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony, if he/she determines that the issues demand it. There are some situations in which I spend on your legal matteram legally obligated to take actions to protect others from harm, even if the request comes from another partyI have to reveal some information about a client’s treatment. [For example, if I charge $500 per hour for professional services believe that a child, dependent older adult or disabled person is being abused, I am asked or may be required to perform in relation file a report to your legal matter. This includes preparation time. I also charge a copying fee of $.50/page for records requested plus a $50 record retrieval fee.] CONTACTING ME I am often not immediately available by telephone. 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 holidays and vacations (scheduled and discussed in advance). Since I am not immediately available, in the case of a true emergency, please call 911 and/or proceed to the nearest emergency roomtake protective action. If I am not available believe that a client is threatening serious bodily harm to another, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for an extended period of timethe client. If the 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. I may occasionally find it helpful to consult with other professionals about a case. During a consultation, I will not reveal the identity of my client. The consultant is also legally bound to keep the information confidential. California law allows me to consult with your medical and mental health treatment providers in order to provide you with the name of best possible care. In such cases, I will ask you to sign a colleague form that gives me permission to contact in case you need to consult a psychotherapist urgentlythese professionals.

Billing and Payments. You will be expected to pay pay-in-full for each session at immediately after the time it is held, unless we have session. Payment of other professional services will be agreed otherwiseupon when they are requested. [In circumstances of unusual financial hardship I hardship, your clinician may be willing to negotiate a fee adjustment or a payment installment plan.] I will accept credit card payment for services. At the time a credit card payment is made, the card must be present. A copy will be made and secured under lock and key. For appointments that are missed or cancelled less that 24 hours in advance you authorize payment for the missed session on you credit card (Initial for agreement of this provision) If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have your clinician has 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, tis its costs will be included in the claim.] . In most collection situations, the only information I will we release regarding the patienta client’s treatment is his/her name, the dates, times nature and nature dates of services provided, and the amountamount due. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on Contacting your legal matter, even if the request comes from another party. [I charge $500 per hour for professional services I am asked or required to perform in relation to your legal matter. This includes preparation time. I also charge a copying fee of $.50/page for records requested plus a $50 record retrieval fee.] CONTACTING ME I am clinician Clinicians are often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequentlyPlease call during normal business hours. I Your call will make every effort to return your call on the same day be returned as soon as possible. If you make it with the exception of holidays and vacations (scheduled and discussed in advance). Since I am not immediately available, in the case of are ever experiencing a true emergency, life-threatening or harm-producing emergency please call 911 and/or proceed “911” or go to the your nearest emergency room. Your clinician does not communicate via text with clients, though her scheduling software and invoicing software will send you reminders of appointments and invoices via text (or email) should you choose to receive them. This should be reviewed verbally in session so that your preferences can be noted and accommodated. Email is also acceptable to discuss scheduling or to transfer documents when mutually agreed upon, however client communication regarding clinical issues or concerns via email (or texting) should be avoided as the delivery of any electronic communication can be intercepted, misdirected, or delayed. Discharged from care Psychotherapy is best ended with a process of termination and a scheduled final appointment. This will allow you to review therapeutic gains achieved during treatment; develop a plan of action to maintain those gains; identify what other services or activities may still be needed; and to process any emotions that may exist regarding the ending of the therapeutic relationship. If I am you decide to end therapy without engaging in the process of termination by not available for an extended period scheduling appointments or by not returning at least two telephone calls, it will be assumed that you are no longer a client of your clinician and you are, therefore, discharged from care. Both the therapist and the client have the right to end counseling at any time, I will provide you . Litigation Limitation Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with the name regard to many matters which may be of a colleague confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to contact divorce and custody disputes, injuries, lawsuits, etc.) neither you (client) nor your attorney, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the therapy records be requested. Mediation and Arbitration All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before and as a pre-condition of, the initial of arbitration. The mediator shall be a neutral third party chosen by agreement of iTherapy, your clinician and you (the client). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorney’s fees. In the case or arbitration, the arbitrator will determine that sum. Agreement Your signature indicates that you need have read this five-page contract; that you understand all that it contains; that you agree to consult a psychotherapist urgentlyabide by its terms; and that you voluntarily consent to treatment. Additionally, your signature below indicates that you understand that I, Xxxx Xxxxxxxx, Psy.D., am an independent practitioner; therefore, iTherapy, and associated providers are not responsible for or involved in your (the client’s) care or treatment unless you directly contracted with that provider. Signature Date Signature (Guarantor Responsible for Fees) Date Please initial if you consent to the willingness to discuss scheduling via:

Billing and Payments. You will be expected to pay for each session either before or at the time it is held, unless we have . Payment schedules for other professional services will be agreed otherwiseto when they are requested. [In circumstances of financial hardship I Payment may be willing to negotiate a fee adjustment made in the form of cash, personal checks, or payment installment plan.] I will accept credit card payment for services. At the time a credit card payment is made, the card must be present. A copy will be made and secured under lock and key. For appointments that are missed or cancelled less that 24 hours in advance you authorize payment for the missed session on you credit card (Initial Visa, MasterCard, American Express or Discover). . It is your responsibility to keep your credit card information up-to-date. If your credit card declines for agreement any reason and you have to be contacted to update that information, there will be a $25 fee. If any amount remains unpaid, no additional sessions will be scheduled until the balance is paid in full. I am a LPC-Intern and therefore I do not accept insurance of this provision) any kind. All services are on a cash, check, or credit card basis. If your account has not been paid for more than 60 45 days and arrangements for payment have not been agreed upon, I have the option of using 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, tis its costs will be included in the claim.] . In most collection situations, the only information I will release regarding the patienta client’s treatment is his/her name, the dates, times and nature of services provided, and the amountamount due. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party. [I charge $500 per hour for professional services I am asked or required to perform in relation to your legal matter. This includes preparation time. I also charge a copying fee of $.50/page for records requested plus a $50 record retrieval fee.] CONTACTING ME Other than session attendance, the only way I am often may be contacted is by calling or texting my number at 000-000-0000. My office hours vary, and I may not be immediately available by telephone. When Calls are generally returned within 24-48 hours during regular business hours. If you do not hear from me within that time frame, you can assume I am unavailable, my telephone is answered by voice mail that I monitor frequentlydid not get your message. I will make every effort Please call back and leave a second message clearly stating your name and number more than once. If you are difficult to return your call on the same day you make it with the exception of holidays and vacations (scheduled and discussed in advance). Since I am not immediately available, in the case of a true emergencyreach, please call 911 and/or proceed inform me of some times when you will be available when leaving a message. Please set your phone to the nearest emergency roomaccept private calls, otherwise I may be unable to reach you. If I am not available for an extended period of time, I Any calls lasting longer than five minutes will provide you with the name of a colleague to contact in case you need to consult a psychotherapist urgentlybe charged $35 per 15 minute increment.

Billing and Payments. You will be expected to pay in full for each session at the time it is held, unless we have agreed otherwiseof service. [In circumstances of financial hardship I may be willing to negotiate a fee adjustment or payment installment plan.] I will accept credit card payment Payment schedules for services. At the time a credit card payment is made, the card must be present. A copy other professional services will be made agreed to when they are requested. Methods of accepted payment are check, cash, and secured under lock credit cards (i.e., MasterCard, Visa, and keyDiscover). For appointments that are missed or cancelled less that 24 hours in advance you authorize payment There is a $5.00 convenience fee for the missed session on you processing credit card (Initial cards. There will be a $35.00 charge for agreement of this provision) returned checks. If your account has not been paid for more than 60 days and arrangements for payment payments have not been agreed upon, I have the option of using legal means to secure payment. This may involve hiring hire a collection agency or going go through small claims court, which will require me to disclose confidential information. [If such legal action is necessary, tis costs will be included in the claim.] In most collection situations, the only information I will release regarding the a patient’s treatment is his/her name, the dates, times and nature of the services provided, and the amountamount due. If legal action is necessary, its costs will be included in the claim. Additional measures may be necessary if your unpaid balance becomes excessive. Because there are times when patients may not pay at the time of sessions (e.g. forgotten checkbooks, minors coming to therapy without parents, missed appointments, etc.), you may be asked to provide a credit card number to keep on file. This credit card information may be used to collect payment or outstanding balances, including appointments missed or rescheduled without the required notice, unless other arrangements are made. Credit cards transactions are processed through Inuit GoPayment, which encrypts its data and complies with Payment Card Industry Data Security Standard. No information about the services provided, other than cost, is shared with the company. INSURANCE REIMBURSEMENT I do not participate in any managed care or insurance agreements, including Tri-Care and Medicare. I am a fee- for-service practice, so you (not your insurance company) are responsible for full payment of my fees. I will provide you with an itemized receipt that you may submit to your insurance company when seeking reimbursement. If you become involved have a health insurance policy, it will usually provide some coverage for mental health treatment. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services and it may be necessary to seek approval for more therapy after a certain number of sessions. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s normal level of functioning. Although much can be accomplished in legal proceedings short-term therapy, some patients decide they need more services after insurance benefits end. Before beginning treatment, it is very important that you ascertain which mental health services your insurance policy covers. If you have questions about coverage, call your insurance plan administrator. Sometimes your insurer may require my participationme to provide clinical information such as treatment plans or summaries, you will be expected to pay for any professional time I spend on or copies of your legal matterentire Clinical Record. If so, even if the request comes from another party. [I charge $500 per hour for professional services I am asked or required to perform in relation to your legal matter. This includes preparation time. I also charge a copying fee of $.50/page for records requested plus a $50 record retrieval fee.] CONTACTING ME I am often not immediately available by telephone. 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 release only the same day minimum information about you make it with that is necessary for the exception of holidays and vacations (scheduled and discussed in advance)purpose requested. Since I am not immediately availableMaryland law prevents insurers from making unreasonable demands for information, in the case of a true emergency, please call 911 and/or proceed to the nearest emergency roombut there are no specific guidelines defining what is unreasonable. If I am not available for an extended period of time, I will provide you with the name a copy of a colleague to contact in case any report I submit, if you need to consult a psychotherapist urgentlyrequest it.

Billing and Payments. You will be expected to I request that you pay for each session at the time it is heldof each session, unless we you have agreed otherwise. [In circumstances of financial hardship I may be willing to negotiate a fee adjustment or payment installment plan.] I will accept credit card payment for services. At the time a credit card payment is madeon file. If I am seeing you regularly, I request that you pay that month's total on the last session of the month. If you have a credit card must be present. A copy on file, your card will be made and secured under lock and key. For appointments that are missed or cancelled less that 24 hours in advance you authorize payment charged once at the end of the month for the missed session on therapy balance from that month. Each month you credit card will also be mailed a statement which reflects your balance. If you carry health insurance (Initial PPO), I will provide you with a filled-out universal insurance form which you can submit to your insurance company for agreement out-of-network reimbursement. However, you will be personally responsible for all charges. You are acknowledging that I am neither a Medicare provider nor a member of this provision) any HMO or PPO insurance panel. If your account has not been paid for more than 60 days and other arrangements for payment have not been agreed uponmade, I have the option of using may use legal means to secure payment. This may involve hiring a collection agency or going through small claims court. [If such legal action is necessary, tis court at which time costs will also be included in the claim.] In most collection situations, the only information I will release regarding the patient’s treatment is his/her name, the dates, times and nature . All disputes arising out of services provided, and the amount. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party. [I charge $500 per hour for professional services I am asked or required to perform in relation to your legal matterthis agreement to provide psychological services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. This includes preparation timeThe mediator shall be a neutral third party chosen by agreement. I also charge The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement will be submitted to and settled by binding arbitration in accordance with the rules of the American Arbitration Association. The prevailing party in arbitration or collection proceedings shall be entitled to recover a copying fee of $.50/page reasonable sum for records requested plus a $50 record retrieval attorneys’ fee.] . CONTACTING ME I am often not immediately available by telephone. When I am unavailable, my telephone is answered by the Office Manager and transferred to a voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it it, with the exception of holidays weekends and vacations (scheduled and discussed in advance)holidays. Since I am not immediately availableavailable by pager so, in the case of a true emergency, please call 911 and/or proceed to the nearest emergency room. If I am not available will be unavailable for an extended period of time, I will provide you with the name of a colleague to contact in case you need to consult a psychotherapist urgently. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep professional records. These are maintained, under lock and key, for a minimum of seven years. You are entitled to receive a copy of the records unless I believe that doing so would endanger the life of you or another. I may recommend that you review them in my presence so we can talk about them.

Billing and Payments. You will be expected to pay for each session at the time it is heldI accept VISA, unless we have agreed otherwiseMasterCard and cheque. [In circumstances of financial hardship I may be willing to negotiate a fee adjustment or payment installment plan.] I will accept credit card payment for services. At the time a credit card payment is made, the card must be present. A copy will be made and secured under lock and key. For appointments that are missed or cancelled less that 24 hours in advance you authorize payment for the missed session on you credit card (Initial for agreement of this provision) 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. [If such legal action is necessary, tis its costs will be included in the claim.] . In most collection situations, the only information I will release regarding the patienta client’s treatment is his/her name, the dates, times and nature of services provided, and the amountamount due. If you become involved in legal proceedings that require Accounts overdue are charged an additional 2% per month on the unpaid balance. INSURANCE REIMBURSEMENT Some health plans provide coverage for my participationservices as a Registered Social Worker, you MSW (Master’s Degree level). It is your responsibility to submit any insurance forms, paperwork, etc. to your insurance company. You will be expected to pay charged for any professional additional paperwork and administration time I spend on your legal matter, even if the request comes from another partybeyond standard billing and invoicing. [I charge $500 per hour for professional services I am asked or required to perform in relation to your legal matter. This includes preparation time. I also charge a copying fee of $.50/page for records requested plus a $50 record retrieval fee.] CONTACTING ME I am often not immediately available by telephoneMy office/client business hours are generally 9:30AM – 5:00PM, Monday thru Saturday. Please consult with my office to find out my in-office schedule for any given week/month. When I am unavailable, my telephone is answered by voice mail that I monitor frequentlyor by my assistant. I We will make every effort to return your call on the same day you make it it, with the exception of holidays weekends and vacations (scheduled holidays. If you are unable to reach me and discussed in advance). Since I am not immediately availablefeel that you can’t wait for me to return your call, in the case of a true emergencycontact your family physician, please call 911 and/or proceed to the nearest emergency room, or call the DISTRESS CENTRE at 266-1605. If I am not available for an extended period of timePROFESSIONAL RECORDS As stated previously, I will provide do not make psychological or mental health diagnoses in my practice. My notes are therefore brief and as such inappropriate for any kind of legal reports or evaluations. Under certain situations, you may have the right to access these notes. CONFIDENTIALITY In general, the privacy of all communications between a client and a social worker are protected by law and I can only release information about our work to others with the name of your written permission. But there are a colleague to contact in case you need to consult a psychotherapist urgentlyfew exceptions.

Billing and Payments. You will be expected to pay for each session at the time it is heldend of each session, unless we have other arrangements are agreed otherwiseupon. [Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship I hardship, we may be willing to negotiate a fee adjustment or payment installment plan.] I will accept credit card payment for servicesadjustment. At the time a credit card payment is made, the card must be present. A copy will be made and secured under lock and key. For appointments that are missed or cancelled less that 24 hours in advance you authorize payment for the missed session on you credit card (Initial for agreement of this provision) If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I we have the option of using 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, tis its costs will be included in the claim.] . In most collection situations, the only information I will we release regarding the a patient’s treatment is his/her name, the dates, times and nature of services provided, and the amountamount due. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party. [I charge $500 per hour for professional services I am asked or required to perform in relation to your legal matter. This includes preparation time. I also charge a copying fee of $.50/page for records requested plus a $50 record retrieval fee.] CONTACTING ME I am US Our therapists are often not immediately available by telephone. When I am unavailable, my telephone is Calls are often answered by voice mail that I monitor frequentlya confidential answering service. I We will make every effort to return your call on within 24 hours of the same day you make it it, with the exception of holidays weekends and vacations (scheduled and discussed in advance)holidays. Since I am not immediately available, in Messages left after regular business hours will generally be returned on the case of a true emergencynext business day. Be sure to leave your telephone number on your message. If you are difficult to reach, please call 911 and/or inform us of some times when you will be available. In an emergency situation, if you are unable to reach your therapist and feel that you cannot wait for me to return your call, please dial 911, or proceed to the nearest hospital emergency roomroom and ask for the psychologist or psychiatrist on call. If I am not available your therapist will be unavailable for an extended period of time, I we will provide you with the name of a colleague to contact contact, if necessary. Due to the nature of electronic communication, we cannot guarantee complete confidentiality of any material you send by email or text. By signing this agreement you acknowledge these risks. If you choose to send emails or texts, your therapist will respond in case you need to consult a psychotherapist urgentlyvague manner as this type of communication is not considered a counseling session. You and your therapist can discuss the contents at your next scheduled session.

Billing and Payments. You will be expected to pay Payment is collected, via credit card, for each session the first appointment at the time it is held, unless we have agreed otherwisebooked. [In circumstances of financial hardship I may All subsequent payments will be willing billed to negotiate a fee adjustment or payment installment plan.] I will accept the credit card payment for services. At near the time a credit of the appointment. The card payment is made, the card must on file will also be presentused for any missed appointments or late cancellations. A copy will Special arrangements can be made and secured under lock and keyfor payment via check or money order. For appointments that are missed or cancelled less that 24 hours in advance you authorize payment for the missed session on you credit card (Initial for agreement of this provision) 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. [If such legal action is necessary, tis its costs will be included in the claim.] In most collection situations, the only information I will release regarding the a patient’s treatment is his/her name, the dates, times and nature of services provided, and amount due. INSURANCE REIMBURSEMENT In order for me to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. I are not currently listed on any insurance panels, which means that I are not “in-network” for any insurance provider. I will give you a receipt and you are welcome to apply for reimbursement of a portion of the amountfee through your insurance provider. I cannot guarantee whether your insurance provider will cover this expense. Many carriers will provide only very limited coverage. Please consult with your insurance carrier prior to starting services. Many insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files. 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. CLIENTS WITH MEDICARE I have opted out of Medicare under under §§1128, 1156 or 1892 of the Social Security Act. If you become involved in are eligible for Medicare but choose to work with a clinician who has opted out of Medicare, then you will have to complete the Patient's Contract For Private Care Contract (xxxxx://xxx.xxxxxxxxxxxxxxxx.xxx/documents /10525/2052366/Opt-Out+Private+Contract). Signing this contract indicates an understanding that you (or your legal proceedings guardian or representative) will be solely responsible for all costs of treatment and that require my participationyou will not seek reimbursement from Medicare. Seeking services from a provider who accepts Medicare may lead to less total cost for you. For more information about Medicare, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party. [I charge $500 per hour for professional services I am asked or required to perform in relation to your legal matter. This includes preparation time. I also charge a copying fee of $.50/page for records requested plus a $50 record retrieval fee.] CONTACTING ME I am often not immediately available by telephone. 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 holidays and vacations (scheduled and discussed in advance). Since I am not immediately available, in the case of a true emergency, please call 911 and/or proceed to the nearest emergency room. If I am not available for an extended period of time, I will provide you with the name of a colleague to contact in case you need to consult a psychotherapist urgently.can visit xxx.xxxxxxxxxxxxxxxx.xxx

Billing and Payments. You will be expected to pay for each session at the time it is held, unless we have agreed agree otherwise. [In circumstances of financial hardship I may accept cash or checks. Other professional services payments will be willing agreed to negotiate a fee adjustment or payment installment plan.] I will accept credit card payment for services. At at the time a credit card payment is made, of the card must be presentrequest. A copy Receipts for therapy will be made and secured under lock and keysent to you if requested. For appointments that are missed If you choose to turn the receipt over to an insurance company or cancelled less that 24 hours in advance you authorize payment for the missed session on you credit card (Initial for agreement of this provision) a third party payer, I CANNOT CONTROL THE SECURITY OF YOUR RECORDS. Remember your receipt often contains a diagnosis. Also insurance companies often require your entire, otherwise protected file. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the legal option of using legal customary means to secure the payment. This may involve hiring a collection agency or going through small claims court. [If such legal action is necessary, tis its costs will be included in the claim.] . In most collection situations, the only information I will release regarding the a patient’s treatment is his/her name, the dates, times and general nature of services provided, and the amountamount due. If PROFESSIONAL RECORDS The laws and standards of my profession require that I keep treatment records. Pursuant to HIPPA, I keep a Protected Health Information (PHI) record which includes information about your reasons for seeking treatment, the way your presenting problem impacts your life, your diagnosis, the goals we set for treatment, your progress towards those goals, your medical and social history, treatment history, and your billing/insurance records. As it states in the Confidentiality Section of this form, I will not release your PHI without your written permission unless in falls into the legal exceptions. PLEASE READ THE CONFIDENTIALITY SECTION OF THIS FORM VERY CAREFULLY. You have the right to obtain your PHI as well as provide me with a written request to amend your PHI. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you become involved review them in legal proceedings my presence so that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if we can discuss the request comes from another partycontents. [I charge $500 per hour for professional services I am asked or required sometimes willing to perform in relation to your legal matter. This includes preparation timeconduct a review meeting without charge. I also charge will be happy to send your records to a copying mental health professional of your choice after you have signed a written release form. Patients will be charged an appropriate fee for any time spent in preparing information requests. MINORS If you are under eighteen years of $.50/page for records requested plus a $50 record retrieval fee.] CONTACTING ME I am often not immediately available by telephone. 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 holidays and vacations (scheduled and discussed in advance). Since I am not immediately available, in the case of a true emergencyage, please call 911 and/or proceed be aware that the law may provide your parents the right to the nearest emergency roomexamine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If I am not available for an extended period of timethey agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the name matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a colleague summary of our work together for your parents, and we will discuss it before I send it to contact in case you need to consult a psychotherapist urgentlythem.

Billing and Payments. You will be If you are a self-pay client, you are responsible for the fees for your therapy, and are expected to pay for each session at the time it is heldof the session unless other arrangements have been made. In the event that you encounter some unusual financial hardship, unless we have agreed otherwise. [In circumstances of financial hardship such as losing your job, I may be willing to negotiate a fee adjustment or payment installment plan.] plan so you can continue receiving therapy during the difficult time. If I am an in-network provider with your insurance program, I will accept gladly verify your benefits for you and bill insurance. Based on your benefits, you may be responsible for some or all of the contracted fee for my services up front (i.e., may not have met your deductible, may have a copay, or may have co-insurance). Payment is due at the time of service. Please understand that I do everything I can to verify your benefits up front. However, in some instances, insurance companies indicate that the services I provide will be covered and then deny benefits later. By signing this services agreement, you are agreeing to leave an active credit card payment for services. At on file that I will bill in the time a credit card payment is made, the card must be present. A copy will be made and secured under lock and key. For appointments that are missed or cancelled less that 24 hours in advance you authorize payment event your insurance company declines to pay for the missed session on services you credit card (Initial received. Whether you are self-pay or an insurance patient, if your balance due becomes very large, or if no payments are made for agreement of this provision) If your account has not been paid for more than 60 days and arrangements for payment have not been agreed uponseveral months, I have the option of using resorting to legal means to secure paymentobtain payment if we cannot work out a payment plan. This may involve hiring could mean involvement of a collection agency or going through small claims court. [If such legal action is necessary, tis costs will be included in the claim.] In most collection situations, the only information I will release regarding the patient’s treatment is his/her name, the dates, times and nature of services provided, and the amountcost of this collection effort would be passed on to you. Such efforts typically require disclosure of some otherwise confidential information, but we will limit this to the minimum information necessary. I accept cash (but cannot make change), checks, and most major credit, debit, and HSA cards. If you become involved in legal proceedings that require my participationchoose to use a card instead of cash or a check to pay your bill, you will be expected assessed an additional 3% swipe fee. You can avoid this fee by paying at the time of your appointment by cash or check. _______ Initial here to pay accept a 3% processing fee when using your credit/debit/HSA card for any professional time I spend on your legal matterpayments. Returned checks will incur a $25 returned check fee. As previously noted, even if the request comes from another party. [I charge $500 per hour for professional services I am asked or required to perform in relation to your legal matter. This includes preparation time. I also charge no-shows and late cancellations will be billed at a copying fee rate of $.50125. _______ Initial here to acknowledge that you are giving me permission to use the card on file to collect late cancellation/page for records requested plus a $50 record retrieval feeno-show fees and returned check fees.] CONTACTING ME I am often not immediately available by telephone. 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 holidays and vacations (scheduled and discussed in advance). Since I am not immediately available, in the case of a true emergency, please call 911 and/or proceed to the nearest emergency room. If I am not available for an extended period of time, I will provide you with the name of a colleague to contact in case you need to consult a psychotherapist urgently.

Billing and Payments. You will be expected to pay for each session I require payment at the time it is held, unless we have agreed otherwiseof service. [In circumstances of financial hardship I may be willing to negotiate a fee adjustment or payment installment plan.] I will accept cash and credit card payment for servicespayments. At the time a For my protection, I require that you provide me (through my accountant) with credit card payment is madeinformation and authorization to charge your card for the balance due. Based on your preference, I can take responsibility to charge the balance due on your card must be presenton a regular basis or only if you have a balance due upon termination of the therapy process. A copy will be made and secured under lock and key. For appointments that are missed or cancelled less that 24 hours in advance By signing this consent, you authorize payment me to charge your credit card for the missed session balance due on you credit card (Initial for agreement of this provision) your account. If your account has not been paid is unpaid for more than 60 days and from the date of service, arrangements for payment have not been agreed upon, and your credit card is declined, I will charge interest of 1.5% per month on any balance. In such a case, I also will have the option of using to use legal means to secure payment. This Under these circumstances, I may involve hiring be required to disclose otherwise confidential information necessary pursue to the claim to a collection agency or going through small claims court. [If such I am compelled to take legal action is necessary, tis costs will be included in the claim.] In most collection situations, the only information I will release regarding the patient’s treatment is his/her name, the dates, times and nature of services provided, and the amount. If you become involved in legal proceedings that require my participationaction, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party. [I charge $500 per hour for professional services I am asked or required to perform in relation to your legal matter. This includes preparation time. I also charge a copying collection fee of $.50/page 50% of the amount due, plus any attorneys’ fees, and court costs. INFORMED CONSENT TO TREATMENT AND PAYMENT I have read and understand the above-described policies and procedures of psychotherapeutic treatment with Xxxxx Xxxxx, LCSW, JD, including those specific to emergencies, confidentiality, billing, payment, and insurance, and I consent to treatment under the conditions described. Client Date CLIENT INFORMATION NAME DATE OF BIRTH AGE PHYSICAL ADDRESS ZIPCODE CELL PHONE EMAIL ADDRESS I specifically authorize Xxxxx Xxxxx, LCSW, JD to charge my credit card, which is stored electronically in her online merchant services system, for records requested plus a $50 record retrieval feethe balance due on my account.] CONTACTING ME I am often not immediately available by telephone. 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 holidays and vacations (scheduled and discussed in advance). Since I am not immediately available, in the case of a true emergency, please call 911 and/or proceed to the nearest emergency room. If I am not available for an extended period of time, I will provide you with the name of a colleague to contact in case you need to consult a psychotherapist urgently.

Billing and Payments. Your payment of the co-pay or session fee is expected at the beginning of each appointment. You will be expected to pay for each session billed at the time it is heldend of each month for any remainder of your balance. Balances that are 60 days past the date of service will be charged to your credit card, unless we other arrangements have agreed otherwisebeen made. [In circumstances of financial hardship I may be willing to negotiate a fee adjustment or situations in which balances are delinquent for 90 days, payment installment plan.] I will accept credit card payment for services. At the time is not collected through a credit card payment card, and no response is madereceived from the patient, the card must be present. A copy account will be made turned over to a professional collection agency, and secured under lock you will be held responsible for any additional legal and key. For appointments that are missed or cancelled less that 24 hours in advance you authorize payment collection agency fees for the missed session on you credit card (Initial for agreement collection of this provision) 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 paymentaccount. This may involve hiring a collection agency or going through small claims court. [If would require me to disclose otherwise confidential information such legal action is necessary, tis costs will be included in the claim.] In most collection situations, the only information I will release regarding as the patient’s treatment is his/her name, the dates, times and nature of the services provided, and the amountamount due. In most cases, a simple phone call response from you will help us to work out an agreement regarding finances. Communications Policies I am generally in the office and will return phone calls Monday-Friday from 9 am–5 pm. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party. [I charge $500 per hour for professional services I am asked or required to perform in relation to your legal matter. This includes preparation time. I also charge a copying fee of $.50/page for records requested plus a $50 record retrieval fee.] CONTACTING ME I am often cannot immediately available by telephone. 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 day, I will try to return it on the next business day. If you make it with the exception are in urgent need of holidays help and vacations (scheduled and discussed in advance). Since I am cannot immediately available, in the case of a true emergencywait for my return call, please call 911 and/or proceed the Multnomah County Crisis Line (000-000-0000), call 911, or go to the nearest hospital emergency room. Administrative issues such as scheduling questions/changes may be handled via phone or email (xxxxxxx@xxxxxxxxxxxxxxxx.xxx) if you prefer. I respond to emails during business hours. Please be aware, email (and texting) are not confidential means of communication, and I do not recommend that you communicate clinical information using those formats. My voicemail (000-000-0000 x0) is confidential. If I go on vacation or am not available otherwise unavailable for an extended period of time, I will provide you with the name and telephone number of a colleague to contact in case you need contact, if needed. To avoid an unethical dual relationship, I will not accept requests made to consult a psychotherapist urgentlyconnect through social media (e.g., Facebook and LinkedIn), except to my professional Instagram account.

Billing and Payments. You If you do not have an insurance plan under which I am a preferred provider, you will be expected to pay for each session at the time it of the session. Receipts can be given after each session. If you will be using insurance, you are responsible for making the claims to your insurance company and for receiving reimbursement (payment) from them for your coverage. I am considered an “out of network provider” in this instance, and, depending on your insurance, you may receive partial reimbursement for these sessions. It is heldimportant for you to know that in order for you to be reimbursed by an insurance company, unless we have agreed otherwise. [In circumstances of financial hardship I may be willing to negotiate a fee adjustment or payment installment plan.] I will accept credit card payment need to include dates and types of service, fees, and diagnoses on the form. It is also possible they will require more information, such as a treatment plan or summary. In such situations, I will make every effort to release only the minimum information about you that is necessary for servicesthe purpose requested. At This information will become part of the time insurance company files and will probably be stored electronically. All insurance companies claim to keep such information confidential, though I have no control over this process. I will provide you with a credit card payment is madecopy of any report I submit at your request. By signing this document, the card must be presentyou agree that I can provide requested information to your carrier. A copy I am glad to provide any necessary documentation required for reimbursement. Payment schedules for other professional services will be made and secured agreed to when they are requested. There are no other forms of payment possible. Neither bartering nor trading for services is allowable under lock and keymy profession’s ethical code, as these constitute a dual relationship. For appointments that are missed With the exception of extreme financial hardship, there will be no reduced fee arrangement or cancelled less that 24 hours in advance you authorize payment for the missed session on you credit card (Initial for agreement of this provision) billing arrangement. 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 courtcourt which will require me to disclose otherwise confidential information. [If such legal action is necessary, tis costs will be included in the claim.] In most collection situations, the only information I will release regarding the patienta client’s treatment is his/her name, the dates, times and nature of services provided, and the amountamount due. (If you become involved in such legal proceedings action is necessary, the costs of that require my participation, you action will be expected to pay for any professional time I spend on your legal matter, even if included in the request comes from another party. [I charge $500 per hour for professional services I am asked or required to perform in relation to your legal matter. This includes preparation time. I also charge a copying fee of $.50/page for records requested plus a $50 record retrieval feeclaim.] CONTACTING ME I am often not immediately available by telephone. 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 holidays and vacations (scheduled and discussed in advance). Since ) INSURANCE REIMBURSEMENT I am not immediately available, in the case of currently a true emergency, please call 911 and/or proceed to the nearest emergency room. If I am not available for an extended period of time, I will provide you provider with the name of a colleague to contact in case you need to consult a psychotherapist urgentlyany insurance companies.

Billing and Payments. I am a fee for service provider. I do not file insurance claims for you, but upon request, I will provide you with all of the information that you should need to make a claim. You may receive reimbursement from your insurance provider if you have “out of network” benefits. This has been successful for a number of my patients. Of course, plans vary, particularly with regard to mental health coverage, and you will need to discuss reimbursement with your insurance provider if you would like to pursue this option. I collect full payment at the time of your visit and then your insurance company will reimburse you directly after you submit your claim. Also, if you plan on billing your insurance for reimbursement of your visit, you will need to obtain a prescription from your physician prior to your first appointment. If you do not plan on billing insurance, you do not need a prescription. Again, I will give you the paperwork and medical diagnosis codes for you to send to your insurance company. You will be expected to pay for each session at the time it is held, unless we have held at the beginning of your session. Payment schedules for other professional services will be agreed otherwiseto when they are requested. [In circumstances of unusual financial hardship hardship, I may be willing to negotiate a fee adjustment or payment installment plan.] I will accept credit card payment for services. At the time a credit card payment is made, the card must be present. A copy will be made and secured under lock and key. For appointments that are missed or cancelled less that 24 hours in advance you authorize payment for the missed session on you credit card (Initial for agreement of this provision) 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. [If such legal action is necessary, tis its costs will be included in the claim.] . In most collection situations, the only information I will release regarding the a patient’s treatment is his/her name, the dates, times and nature of services provided, and the amountamount due. If You should also be aware that most insurance companies require you become involved to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party. [I charge $500 per hour for professional services I am asked or required to perform in relation to your legal matterrare cases). This includes preparation timeinformation 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 also charge will provide you with a copying fee copy of $.50/page for records requested plus a $50 record retrieval feeany report I submit, if you request it. Contacting Me.] CONTACTING ME I am often not immediately available by telephone. When While I am unavailableusually in my office between 9 AM and 5 PM, my telephone is answered by voice mail that Monday through Friday I monitor frequentlywill not answer the phone when I am with a patient. I will make every effort to return your call on the same day you make it it, with the exception of holidays weekends and vacations (scheduled and discussed in advance)holidays. Since I am not immediately available, in the case of a true emergencyIf you are difficult to reach, please call 911 and/or proceed 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, contact your family physician or the nearest emergency roomroom and ask for the psychologist [psychiatrist] on call. You may also call the EMPACT psychological crisis line at 000-000-0000. If I am not available will be unavailable for an extended period of time, I will provide you with the name of a colleague to contact in case you need to consult a psychotherapist urgentlycontact, if necessary.

Billing and Payments. You will be expected to pay are responsible for paying for each session upon arrival at my office at the time it is held, unless we have agreed otherwisebeginning of your session. [In circumstances of financial hardship I may be willing to negotiate accept cash and credit cards (with a fee adjustment or payment installment plan.] I will accept credit card payment $5 fee) as payment. Payment schedules for services. At the time a credit card payment is made, the card must be present. A copy other professional services will be made and secured under lock and keyagreed to when they are requested. For appointments that are missed or cancelled less that 24 hours in advance you authorize payment for the missed session on you credit card (Initial for agreement of this provision) 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. [If such legal action is necessary, tis costs will be included in the claim.] In most collection situations, the only information I will release regarding the a patient’s treatment is his/her name, the dates, times and nature of services provided, and the amountamount 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 become involved in legal proceedings that require my participationhave a health insurance policy, it will usually provide some coverage for mental health treatment. However, you (not your insurance company) are responsible for full payment of my fees. I do not currently accept health insurance. Payment is due at the time of service. I have found that working independently from insurance providers allows clients more flexibility and freedom to choose who they see for psychotherapy without the constraints of having to seek treatment “in network.” I encourage you to contact your insurance provider directly, as many clients are able to get reimbursed for their treatment. Although I am willing to help in any way that I can to assist with this process, it is ultimately up to you to make arrangements with your provider to reimburse you directly. Please be aware that insurance will be expected to not pay for any professional time I spend on missed appointments, and that complete payment for services rendered and missed appointments is your legal matterresponsibility. Monthly receipts are available to all clients, even if the request comes from another partyand are used by many to receive reimbursement for my out of network psychotherapy services. [I charge $500 per hour for professional services I am asked or required to perform in relation to your legal matter. This includes preparation time. I also charge a copying fee of $.50/page for records requested plus a $50 record retrieval fee.] CONTACTING ME I am often not immediately available by telephone. While I am usually in my office on Fridays between 8am and 6pm, I will not answer the phone when I am with a client. When I am unavailable, you may leave me a message on my telephone is answered by voice confidential voice-mail that I monitor frequently. I will make every effort to return your call on the same day you make it within 24 hours, with the exception of holidays weekends and vacations (scheduled and discussed in advance). Since I am not immediately available, in the case of a true emergency, please call 911 and/or proceed to the nearest emergency roomholidays. If I am not available will be unavailable for an extended period of time, I will provide you with the name of a colleague to contact, if necessary. If you are experiencing an emergency and are unable to reach me or feel that you can’t wait for me to return your call, contact in case 911 or the Crisis Clinic at (000) 000-0000. If you need believe that you can’t keep yourself safe, please call 911, or go to consult a psychotherapist urgentlythe nearest hospital emergency room and request to talk to the psychologist or psychiatrist on call.

Billing and Payments. You will be expected to pay for each session at the time it is heldbeginning of the session, unless we have agreed a written agreement (fee form) otherwise, or unless you have insurance coverage, which requires another arrangement. [In circumstances I am a preferred provider for Blue/Cross/Blue Shield and Tri-Care and a number of financial hardship I additional carriers and MHBS will bill them in accordance to our agreement. MHBS will check your benefits for me. However, please be advised that some insurance companies may be willing to negotiate a fee adjustment or payment installment plan.] I will accept credit card payment not pay for my services. At the time a credit card payment is made, the card must be present. A copy It will be made and secured under lock and keyyour responsibility to check with your insurance carrier about your benefits. For appointments that Regardless of insurance coverage, you are missed or cancelled less that 24 hours in advance you authorize payment responsible for the missed session on you credit card (total charges incurred. Payment schedules for other professional services will be agreed to when they are requested. Initial for agreement of this provision) If your account has not been paid for more than 60 30 days and payment 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 clams court. [If such legal action is necessary, tis its costs will be included in the claim.] In most collection situations, the only information I will release regarding the patienta client’s treatment is his/her name, the dates, times and nature of services provided, and the amount. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party. [I charge $500 per hour for professional services I am asked or required to perform in relation to your legal matter. This includes preparation timeamount due. I also charge a copying fee of $.50/page for records requested plus a $50 record retrieval fee.] prefer not to use this option and ask that you promptly speak to me about any financial problems you may be having. Initial CONTACTING ME I am often not immediately directly available by telephone. When I am unavailable, my My telephone is answered by a confidential voice mail. Although I am with clients most of the day, I check my voice mail that I monitor frequentlyperiodically throughout the day. I will make every effort to return your call on by the close of the same day you make it business day, with the exception of holidays weekends and vacations (scheduled holidays. If you are unable to reach me and discussed in advance). Since I am not immediately available, in the case of a true emergencybelieve you can’t wait for me to return your call, please call 911 and/or proceed South Central Counseling Center’s 24-hour crisis line (563- 3200) or go to the nearest hospital emergency room. If I am not available will be unable for an extended period period, I will leave a message on my voice mail and discuss availability options with you during a regular scheduled appointment. Initial Please leave your brief message on the voice mail speaking slowly, repeating and spelling your first and last name, repeating your confidential phone number at which I may leave a message and a couple of timetimes that you may be available. I will do my best to reach you at one of those times. Initial PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. You are entitled to receive a summary of your records. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, I recommend that you review them in session, so that we can discuss the contents or have them forwarded to another mental health professional to review with you. There may be a charge for preparation of the summary of your records and/or for my time to review the records with you. Initial MINORS If you are under eighteen (18) years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from your parents that they waive the right of access to your records. If they agree, I will provide them only with general information about our work together, unless I believe there is a high risk that you will seriously harm yourself or someone else. In these cases, I will notify them of my concern. (Up to this point, I have not needed to breech confidentiality with the name minor as I have worked with the minor to verbalize his/her risk of harm to their parents.) If they agree, I will have them sign an agreement, which will ensure the confidentiality of our sessions. It should be known that at any time your parents may revoke the confidentiality agreement. From the moment they revoke this agreement, they have access to any information obtained from that moment forward. Information gathered while the agreement is in effect is still protected. At the end of your treatment, I will prepare a colleague summary statement of our work, if it is requested by your parents and we will discuss the summary before it is released to your parents. Before giving them any information, I will discuss the information with you, if possible and do my best to appropriately resolve any objections you may have. I, (parent/Legal Guardian) n this date, agree to complete confidentiality of the records for (minor child/ other: specify- ) until revoked in writing. I understand that any information obtained from this date forward is privileged, and that I will not have access to any information obrained between this date and the date that I revoke, in writing, this agreement. I agree that only information obtained after revocation of this confidentiality agreement will be available for my review. Parent/Legal Guardian Signature Parent/Legal Guardian Signature Parent/Legal Guardian Printed Name Parent/Legal Guardian Printed Name Date: Date: Printed Name: Date: Signature: LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a patient and a counselor. 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 HIPPA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 inform you about these consultations unless I believe that it is important to achieving your collaborated treatment goals. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Counselor’s Polices and Practes to Protect the Privacy of Your Health Information). • Disclosure required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If a patient 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 case a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the counselor-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization • or a court order. If you need are involved or contemplating litigation, you should consult with your attorney to consult determine whether a psychotherapist urgentlycourt would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I am 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. 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. o If I have reasonable cause to suspect that a child has suffered harm as a result of child abuse or neglect, the law requires that I file a report with the appropriate governmental agency, usually the Office of Children’s Services (OCS). o If I have reasonable cause to believe that a vulnerable adult suffers from abandonment, exploitation, abuse, neglect, or self-neglect; or that a disabled person has been abused, the law requires that I file a report with adult protective services and/or police department. o If a patient communicates an immediate threat of serious physical harm to an identifiable victim, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will try to limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. 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 also indicates that you have received a copy of “Notice of Policies and Practices to Protect the Privacy of Your Health Information.” If the client is a minor and you are the Legal Guardian, your signature below also acknowledges the activation of the minor child’s right to session confidentiality until revoked in writing. Signature: Legal Guardian if client is under eighteen Date Client Signature Date