Common use of Billing and Payments Clause in Contracts

Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. I accept cash, checks, Visa and MasterCard. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. Accounts are due 45 days after the date of service. Overdue accounts may be charged interest at a rate of 1.5% per month. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the 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 action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT There are many different insurance plans and reimbursement options, and I am not able to keep track of them all. It is your responsibility to know your level of coverage for services with me. I recommend all clients contact their insurance company to ask about plan coverage, co-pays, co-insurance, and deductibles, referencing Xxx Xxxxxxxxx, PsyD, LP as your provider. If you elect to use your health insurance coverage, you should be aware that most insurance companies require that I provide them with your clinical diagnosis and dates of services for billing purposes. Sometimes, insurance companies request additional clinical information, such as treatment plans, progress notes or summaries, or copies of the entire records (in rare cases). Although all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. You understand that, by using your insurance, you authorize me to release necessary information to your insurance company. I will try to keep that information limited to the minimum necessary. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. CANCELLED/MISSED APPOINTMENTS A scheduled appointment means that time is reserved only for you. If an appointment is missed or cancelled with less than 24-hours notice, you will be billed directly according to the scheduled fee or according to the rules of your insurance plan. Your insurance plan does not cover payment for missed appointments; therefore, you are responsible for payment in full. Repeated cancellations and missed appointments may result in termination of the therapeutic relationship. A letter reflecting termination will be mailed to you should this occur.

Billing and Payments. You will be expected requested to pay for complete a credit card authorization form prior to beginning services. Your credit card will be charged after each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. I accept cash, checks, Visa and MasterCard. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. Accounts are due 45 days after the date of service. Overdue accounts may Summit Center has the right to postpone additional services if a prior account balance has not been paid, if the credit card on file cannot be charged interest at a rate of 1.5% per monthauthorized, or if prior payment arrangements have not been made. 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 which will require me to disclose otherwise confidential informationcourt. In most collection situations, the only information I release released regarding a patientclient’s treatment is his/her name, the nature of services provided, and the amount due. If such action is necessary, its costs will be included in the claimOur Billing Department can answer any questions or address billing concerns at xxxxxxx@xxxxxxxxxxxx.xx. INSURANCE REIMBURSEMENT There REIMBURSEMENT: Clients who carry insurance should remember that professional services are many different rendered and charged to the clients and not to the insurance plans and reimbursement optionscompany. Upon request, and I am not able Summit Center can provide Superbills, which you can then submit to keep track of them all. It is your responsibility to know your level of coverage for services with me. I recommend all clients contact their insurance company to ask about plan coverage, co-pays, co-insurance, and deductibles, referencing Xxx Xxxxxxxxx, PsyD, LP as your providerfor reimbursement if you so choose. If you elect to use your health insurance coverage, you You should be aware that most insurance companies require that I you to authorize Summit Center to provide them with your a clinical diagnosis and dates of services for billing purposesdiagnosis. Sometimes, insurance companies request Sometimes additional clinical information, information such as treatment plans, progress notes plans or summaries, or copies summaries are needed. This information will become part of the entire records (insurance company files and will probably be stored in rare cases)a computer. Although all Though insurance companies claim to keep such information confidential, I have Summit Center has no control over what they do with it this confidential information once it is in their hands. You understand that, Not all mental health related services/diagnoses or conditions are reimbursed by using your insurance, you authorize me to release necessary information to your insurance company. I will try to keep that information limited to the minimum necessarycompanies. It is important your responsibility to remember verify the specifics of your coverage. CONTACTING US: While we are usually in the office between 8:30am-5pm, we may not be immediately available by telephone. When unavailable, our telephone is answered by voicemail. Please note that our administrative staff will make every effort to return your call within 24 business hours. If you always have are unable to reach us and feel you cannot wait for a returned call, contact your family physician or the nearest emergency room and ask for the psychologist on call. If your mental health practitioner will be unavailable for an extended time, we will provide you with the name of a colleague to contact, if necessary. MINORS: If you are under 18 years of age, please be aware that the law may provide your parents the right to pay examine your treatment records. It is our policy to request an agreement from your parents that they agree to give up access to your records. If they agree, we will provide them only with general information about our work together, unless we feel there is high risk that you will seriously harm yourself or someone else. In this case, we will notify them of our concern. RESEARCH: Summit Center contributes to the scientific community by integrating research into our practice. We would like your permission to use your or your child’s testing data anonymously for my services yourself research. All identifying information (e.g., names, birthdays, background information, etc.) will be removed. In addition, data will be aggregated so the individual client’s data will not be identifiable. There are no foreseeable risks or discomforts to avoid the problems described aboveclient for taking part in this study, and this study will be handled in a highly confidential manner. CANCELLED/MISSED APPOINTMENTS A scheduled appointment means Only Summit center staff who de-identify the files will know that time you have decided to provide permission for the data to be used. Outside researchers will never have access to you or your child's identity. Any reports or publications based on this research will use only group data and will not identify you or your child or any individual as being part of this project. The decision to participate in this research is reserved only for up to you. We will be happy to answer any questions you have about our ongoing studies. If an appointment is missed you have further questions about this project or cancelled with less than 24-hours noticehave a research- related problem, you will be billed directly according may contact the principal investigator, Xxxxxxx Xxxx, Psy.D., or our Research Associate, Xxxxxxxxx Xxxxx, M.S. I give consent for the Research Team at Summit Center to the scheduled fee or according to the rules of your insurance plan. Your insurance plan does not cover payment use my/my child's information for missed appointments; therefore, you are responsible for payment in full. Repeated cancellations and missed appointments may result in termination of the therapeutic relationship. A letter reflecting termination will be mailed to you should this occurresearch at Summit Center.

Billing and Payments. You will be expected to pay for each session services at the time it is heldthey are rendered, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. I accept cash, checks, Visa and MasterCard. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. Accounts are due 45 days after the date of service. Overdue accounts may be charged interest at a rate of 1.5% per monthotherwise. 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 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 those costs will be included in the claim. INSURANCE REIMBURSEMENT There 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 and/or testing. While I will provide you with whatever assistance I can in helping you receive the benefits to which you are many different entitled, you (not your insurance plans and reimbursement options, and I am not able to keep track company) are responsible for full payment of them allmy fees. It is therefore very important that you find out the extent to which my services are reimbursable through your responsibility to know insurance company. You should carefully read the section in your level of insurance coverage for services with me. I recommend all clients contact their insurance company to ask about plan coverage, co-pays, co-insurance, and deductibles, referencing Xxx Xxxxxxxxx, PsyD, LP as your providerbooklet that describes mental health services. If you elect to use have questions about the coverage, call your plan administrator or human resources consultant. You should also be aware that your contract with your health insurance coverage, you should be aware that most insurance companies company may require that I provide them with your information relevant to the services that I provide to you in order for you to obtain reimbursement. Your account statement provides the information most commonly requested (e.g., clinical diagnosis and dates diagnoses, CPT codes, date of services for billing purposes. Sometimesservice, etc.) Your health insurance companies company may request additional clinical information, information such as treatment plans, progress notes plans or summaries, or even copies of your entire record (although this is not common.) In such situations, I will make every effort to release only the entire records (minimum information about you that is necessary for the purpose requested and only upon your request. This information will become part of the insurance company files and will probably be stored in rare cases)a computer. Although 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. You understand thatIn some cases, by using your insurancethey 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 authorize me to release necessary agree that I can provide requested information to your insurance company. I will try to keep that information limited to the minimum necessary. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. CANCELLED/MISSED APPOINTMENTS A scheduled appointment means that time is reserved only for you. If an appointment is missed or cancelled with less than 24-hours notice, you will be billed directly according to the scheduled fee or according to the rules of above (unless expressly prohibited by your insurance plan. Your insurance plan does not cover payment policy.) Paying for missed appointments; therefore, my services yourself provides maximal privacy protection and control over the services you are responsible for payment in full. Repeated cancellations and missed appointments may result in termination of the therapeutic relationship. A letter reflecting termination will be mailed to you should this occurreceive.

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 arrangementotherwise. I accept cash, checks, Visa and MasterCardPayment 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. Accounts are due 45 days after the date of service. Overdue accounts may be charged interest at a rate of 1.5% per monthPlease discuss this with me if this need arises). 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 court. (If such legal action is necessary, its costs will require me to disclose otherwise confidential information. be included in the claim.) In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, provided and the amount due. If such action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT There 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 assistance I can in helping you receive the benefits to which you are many different entitled; however, you (not your insurance plans and reimbursement options, and 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. I am not able to keep track of them all. It is your responsibility to know your level of coverage for services with me. I recommend all clients contact their on any insurance company to ask about plan coveragepanels, co-pays, co-insurance, and deductibles, referencing Xxx Xxxxxxxxx, PsyD, LP as your provider. If you elect to use your health insurance coveragetherefore, you will be responsible for collecting from your insurance plan the mental health benefits that are reimbursable through your plan. You should be aware that most insurance companies require that I you to authorize me to provide them with your a clinical diagnosis and dates of services for billing purposesdiagnosis. Sometimes, insurance companies request Sometimes I have to provide additional clinical information, information such as treatment plans, progress notes plans or summaries, or copies of the entire records record (in rare cases). Although 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. You understand thatIn some cases, by using your insurancethey may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you authorize me to request it. I will request you provide me, in writing, a release necessary that I provide this information to your insurance company. CONTACTING ME I am often not immediately available by telephone, as I am in sessions. While I am usually in my office between 9 AM and 6 PM, Monday-Thursday, I probably will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by an answering voice mail, or by my secretary whom you can reach by dialing “0” (that I monitor frequently, or who knows where to reach me). I will try make every effort to keep that information limited to return your call within 48 hours you make it, with the minimum necessary. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. CANCELLED/MISSED APPOINTMENTS A scheduled appointment means that time is reserved only for youexception of Fridays, weekends and holidays. If an appointment is missed or cancelled with less than 24-hours noticeyour are also not immediately available, please inform me of some times when you will be billed directly according to available. (in emergencies and urgent matters, my urgent pager number of 000-000-0000, ext 208 which has directions on the scheduled fee or according to options in the rules event of your insurance plana mental health emergency.). Your insurance plan does not cover payment for missed appointments; therefore, If you are responsible unable to reach me and feel that you can’t wait for payment in fullme to return your call, contact your family physician or the nearest emergency room and ask for the psychologist (psychiatrist) on call. Repeated cancellations and missed appointments may result in termination of the therapeutic relationship. A letter reflecting termination If I will be mailed unavailable for an extended time, I will provide you with the name of a colleague to you should this occurcontact, if necessary. On the AAFPC website; XXXXX.xxx.

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. I accept cash, checks, Visa and MasterCard. In circumstances of unusual financial hardship, I may Payment schedules for other professional services will be willing agreed to negotiate a fee adjustment or payment installment plan. Accounts when they are due 45 days after the date of service. Overdue accounts may be charged interest at a rate of 1.5% per monthrequested. 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. INSURANCE REIMBURSEMENT There are many different insurance plans Insurance Reimbursement In order for us to set realistic treatment goals and reimbursement optionspriorities, and I am not able it is important to keep track of them all. It is evaluate what resources you have available to pay for your responsibility to know your level of coverage for services with me. I recommend all clients contact their insurance company to ask about plan coverage, co-pays, co-insurance, and deductibles, referencing Xxx Xxxxxxxxx, PsyD, LP as your providertreatment. If you elect have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide assistance in receiving the benefits to use which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. 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. Your contract with your health insurance coverage, you should be aware that most insurance companies require company requires that I provide them it with your clinical diagnosis information relevant to the services that I provide to you. Information typically requested includes the diagnosis, current symptoms, treatment plan, and dates of services for billing purposesprogress. Sometimes, insurance companies request additional clinical information, such as treatment plans, progress notes or summaries, or copies This information will become part of the entire records (insurance company files and will probably be stored in rare cases)a computer. Although all insurance Insurance companies claim are supposed to keep such information confidential. In some cases, I have no control over what they do may share the information with it once it is in their handsa national medical information databank. You understand that, by using your insuranceBy signing this Agreement, you authorize me to release necessary agree that I can provide requested information to your insurance companycarrier. 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: Signature: Date: Assignment of Benefits I hereby authorize the release of any medical or other information necessary to process claims. I will try also request payment of government or other insurance benefits either to keep that information limited myself or to the minimum necessary. It is important to remember that you always have party who accepts assignment of benefits on the right to pay for my services yourself to avoid the problems described above. CANCELLED/MISSED APPOINTMENTS A scheduled appointment means that time is reserved only for you. If an appointment is missed or cancelled with less than 24-hours notice, you will be billed directly according to the scheduled fee or according to the rules of your insurance plan. Your insurance plan does not cover payment for missed appointments; therefore, you are responsible for payment in full. Repeated cancellations and missed appointments may result in termination of the therapeutic relationship. A letter reflecting termination will be mailed to you should this occurHCFA Form 1500 Health Insurance Claim Form.

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 arrangementotherwise. I accept the following methods of payment: credit card, check, and cash, checks, Visa and MasterCard. In circumstances of unusual financial hardship, I may Checks need to be willing made out to negotiate a fee adjustment or payment installment planme. Accounts Late charges will be added to accounts with any balance over 30 days old. Late fees are due 45 days after the date of service. Overdue accounts may be charged interest calculated at a rate of 1.52% per monthmonthly. If your account has not been paid for more than 60 days and arrangements for payment you have not been agreed uponarranged payment, I have the option of using legal means to secure the payment. This may involve hiring a , including collection agency agencies or going through small claims court which will require me to disclose otherwise confidential informationclaims. In most collection situations, the only information I release released 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 the costs will be included in the claim. .) INSURANCE REIMBURSEMENT There are many different insurance plans In order for us to set realistic goals and reimbursement optionspriorities, and it is important to evaluate what resources you have available to pay for your treatment because I am not able an out-of-network provider for all insurance companies. As a courtesy, I can electronically submit a claim form on your behalf; however, I strongly encourage you to keep track of them all. It is contact your responsibility insurance company prior to know services to determine your level of coverage out-of-network benefits and for services with meyou to request pre-authorization if necessary. I recommend all clients contact their cannot guarantee reimbursement from your insurance company to ask about plan coveragecompany. You should also be aware that if you request reimbursement from your insurance carrier, co-pays, co-insurance, and deductibles, referencing Xxx Xxxxxxxxx, PsyD, LP as your provider. If you elect to use contract with your health insurance coverage, you should be aware that most insurance companies require carrier requires that I provide them with your information relevant to the services that I provide to you. I am required to provide a clinical diagnosis and dates of services for billing purposesa service code. Sometimes, insurance companies request Sometimes I am required to provide additional clinical information, information such as treatment plans, progress notes plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only minimum information about you that is necessary for the entire records (in rare cases)purpose requested. Although This information will become part of the insurance company files and will probably be stored electronically. 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. You understand thatIn some cases, by using your insurance, you authorize me to release necessary they may share the information to your insurance companywith a national medical information databank. I will try to keep that information limited to the minimum necessary. It is important to remember that provide you always have the right to pay for my services yourself to avoid the problems described above. CANCELLED/MISSED APPOINTMENTS A scheduled appointment means that time is reserved only for you. If an appointment is missed or cancelled with less than 24-hours noticea copy of any report I submit, if you will be billed directly according to the scheduled fee or according to the rules of your insurance plan. Your insurance plan does not cover payment for missed appointments; therefore, you are responsible for payment in full. Repeated cancellations and missed appointments may result in termination of the therapeutic relationship. A letter reflecting termination will be mailed to you should this occurrequest it.

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 arrangementotherwise. I accept cash, checks, Visa and MasterCard. In circumstances of unusual financial hardship, I may Payment schedules for other professional services will be willing agreed to negotiate a fee adjustment or payment installment plan. Accounts when they are due 45 days after the date of service. Overdue accounts may be charged interest at a rate of 1.5% per monthrequested. 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 the services provided, and the amount due. If such legal action is necessary, its costs the cost incurred will be included in the claim. INSURANCE REIMBURSEMENT There are Insurance Reimbursement Often, nutrition therapy is not a covered benefit under many different insurance plans and reimbursement optionspolicies. For this reason, and I am do not able to keep track of them all. It is your responsibility to know your level of coverage file insurance claims for services with me. I recommend all clients contact their insurance company to ask about plan coverage, co-pays, co-insurance, and deductibles, referencing Xxx Xxxxxxxxx, PsyD, LP as your providermy clients. If you elect choose to use your health insurance coveragefile a claim for nutrition services, you may submit the receipt I provide to your insurance company. If additional information is needed, the insurance company will contact me directly and I will do my best to provide them with the necessary information. You should be aware that most if you choose to file a claim with your insurance companies require company, I am required to provide it with information relevant to the services that I provide them with your to you. I am required to provide a clinical diagnosis and dates of services for billing purposesdiagnosis. Sometimes, insurance companies request Sometimes I am required to provide additional clinical information, information such as treatment plans, progress notes plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the entire records (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 rare cases)a computer. Although 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. You understand thatIn some cases, by using your insurancethey 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 authorize me to release necessary agree that I can provide requested information to your insurance company. I will try to keep that information limited to the minimum necessarycarrier. It is important to remember that you always do not have the right to pay submit nutrition therapy charges to your insurance company for my services yourself to avoid reimbursement, thereby avoiding the problems described above. CANCELLED/MISSED APPOINTMENTS A scheduled appointment means that time is reserved only for Please bring this page signed to your clinician at your first appointment. Thank you. If an appointment is missed or cancelled with less than 24-hours noticeXxxxx Xxxxx, you will be billed directly according to the scheduled fee or according to the rules RD, LD Informed Consent & Client Services Agreement YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO IT’S TERMS DURING OUR PROFESSIONAL RELATIONSHIP AND GIVE INFORMED CONSENT TO RECEIVE SERVICES FROM XXXXX XXXXX, RD, LD. IT ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. Patient Signature Date Signature of your insurance plan. Your insurance plan does not cover payment for missed appointments; therefore, you are responsible for payment in full. Repeated cancellations and missed appointments may result in termination of the therapeutic relationship. A letter reflecting termination will be mailed to you should this occur.Parent or

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 arrangementotherwise. I accept cash, checks, Visa and MasterCardPayment 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. Accounts are due 45 days after the date of service. Overdue accounts may be charged interest at a rate of 1.5% per month. .] If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the 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. .] INSURANCE REIMBURSEMENT There If you have a health insurance policy, I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are many different entitled; however, you (not your insurance plans and reimbursement options, and I am not able to keep track company) are responsible for full payment of them allmy fees. It is very important that you find out exactly what health services your responsibility to know insurance policy covers. You should also be aware that your level of coverage for services contract with me. I recommend all clients contact their insurance company to ask about plan coverage, co-pays, co-insurance, and deductibles, referencing Xxx Xxxxxxxxx, PsyD, LP as your provider. If you elect to use your health insurance coverage, you should be aware that most insurance companies require company requires that I provide them it with your information relevant to the services that I provide to you. I am required to provide a clinical diagnosis and dates of services for billing purposesdiagnosis. Sometimes, insurance companies request Sometimes I am required to provide additional clinical information, information such as treatment plans, progress notes plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the entire records (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 rare cases)a computer. Although 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. You understand thatIn some cases, by using your insurancethey 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 authorize me to release necessary agree that I can provide requested information to your insurance companycarrier. I will try to keep that information limited to the minimum necessary. It is important to remember Your signature below indicates that you always have read the right information in this document and agree to pay for my services yourself to avoid the problems described aboveabide by its terms during our professional relationship. CANCELLED/MISSED APPOINTMENTS A scheduled appointment means Acknowledgement of Receipt of Privacy Notice ( HIPAA) I acknowledge that time is reserved only for you. If an appointment is missed or cancelled with less than 24-hours notice, you will be billed directly according to the scheduled fee or according to the rules of your insurance plan. Your insurance plan does not cover payment for missed appointments; therefore, you are responsible for payment in full. Repeated cancellations and missed appointments may result in termination I have received a copy of the therapeutic relationshipoffice’s Notice of Privacy Practices for Protected Health Information (HIPAA). A letter reflecting termination will be mailed Signed: Date Patient or Legally Authorized Individual Printed Name: Relationship to you should this occur.Patient:  Self Parent Legal Guardian Other:

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. I accept cash, checks, Visa and MasterCard. In circumstances of unusual financial hardship, I may Payment schedules for other professional services will be willing agreed to negotiate a fee adjustment or payment installment plan. Accounts when they are due 45 days after the date of service. Overdue accounts may be charged interest at a rate of 1.5% per monthrequested. 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. INSURANCE REIMBURSEMENT There are many different insurance plans Insurance Reimbursement In order for us to set realistic treatment goals and reimbursement optionspriorities, and I am not able it is important to keep track of them all. It is evaluate what resources you have available to pay for your responsibility to know your level of coverage for services with me. I recommend all clients contact their insurance company to ask about plan coverage, co-pays, co-insurance, and deductibles, referencing Xxx Xxxxxxxxx, PsyD, LP as your providertreatment. If you elect have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide assistance in receiving the benefits to use which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. 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. Your contract with your health insurance coverage, you should be aware that most insurance companies require company requires that I provide them it with your clinical diagnosis information relevant to the services that I provide to you. Information typically requested includes the diagnosis, current symptoms, treatment plan, and dates of services for billing purposesprogress. Sometimes, insurance companies request additional clinical information, such as treatment plans, progress notes or summaries, or copies This information will become part of the entire records (insurance company files and will probably be stored in rare cases)a computer. Although all insurance Insurance companies claim are supposed to keep such information confidential. In some cases, I have no control over what they do may share the information with it once it is in their handsa national medical information databank. You understand that, by using your insuranceBy signing this Agreement, you authorize me to release necessary agree that I can provide requested information to your insurance companycarrier. 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: _Signature: Date: Assignment of Benefits I hereby authorize the release of any medical or other information necessary to process claims. I will try also request payment of government or other insurance benefits either to keep that information limited myself or to the minimum necessary. It is important to remember that you always have party who accepts assignment of benefits on the right to pay for my services yourself to avoid the problems described above. CANCELLED/MISSED APPOINTMENTS A scheduled appointment means that time is reserved only for you. If an appointment is missed or cancelled with less than 24-hours notice, you will be billed directly according to the scheduled fee or according to the rules of your insurance plan. Your insurance plan does not cover payment for missed appointments; therefore, you are responsible for payment in full. Repeated cancellations and missed appointments may result in termination of the therapeutic relationship. A letter reflecting termination will be mailed to you should this occurHCFA Form 1500 Health Insurance Claim Form.

Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise otherwise, or unless you have insurance coverage that requires another arrangement. I accept cash, checks, Visa and MasterCard. In circumstances of unusual financial hardship, I may Payment schedules for other professional services will be willing agreed to negotiate a fee adjustment or payment installment plan. Accounts when they are due 45 days after the date of service. Overdue accounts may be charged interest at a rate of 1.5% per month. 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 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 '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. .] INSURANCE REIMBURSEMENT There 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 assistance I can in helping you receive the benefits to which you are many different entitled; however, you (not your insurance plans and reimbursement options, and I am not able to keep track company) are responsible for full payment of them allmy fees. It is very important that you find out exactly what mental health services your responsibility to know insurance policy covers. You should carefully read the section in your level of insurance coverage for services booklet that describes mental health services. You should also be aware that your contract with me. I recommend all clients contact their insurance company to ask about plan coverage, co-pays, co-insurance, and deductibles, referencing Xxx Xxxxxxxxx, PsyD, LP as your provider. If you elect to use your health insurance coverage, you should be aware that most insurance companies require company requires that I provide them it with your information relevant to the services that I provide to you. I am required to provide a clinical diagnosis and dates of services for billing purposesdiagnosis. Sometimes, insurance companies request Sometimes I am required to provide additional clinical information, information such as treatment plans, progress notes plans or summaries, or copies of the your entire records (in rare cases)Clinical Record. Although all insurance companies claim to keep In such information confidentialsituations, I have no control over what they do with it once it will make every effort to release only the minimum information about you that is in their handsnecessary for the purpose requested. You understand that, by using your insuranceBy signing "The Acknowledgement Notice", you authorize me to release necessary agree that I can provide requested information to your insurance company. I will try to keep that information limited to the minimum necessary. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. CANCELLED/MISSED APPOINTMENTS A scheduled appointment means that time is reserved only for you. If an appointment is missed or cancelled with less than 24-hours notice, you will be billed directly according to the scheduled fee or according to the rules of your insurance plan. Your insurance plan does not cover payment for missed appointments; therefore, you are responsible for payment in full. Repeated cancellations and missed appointments may result in termination of the therapeutic relationship. A letter reflecting termination will be mailed to you should this occurcarrier.

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. I accept cash, checks, Visa and MasterCardPayment 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. Accounts are due 45 days after the date of service. Overdue accounts may be charged interest at a rate of 1.5% per month. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which court. If such legal action is necessary, its costs will require me to disclose otherwise confidential informationbe included in the claim. 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 action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT There 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 assistance I can in helping you receive the benefits to which you are many different entitled; however, you (not your insurance plans and reimbursement options, and I am not able to keep track company) are responsible for full payment of them allmy fees. It is very important that you find out exactly what mental health services your responsibility to know insurance policy covers. You should carefully read the section in your level of insurance coverage for services with me. I recommend all clients contact their insurance company to ask about plan coverage, co-pays, co-insurance, and deductibles, referencing Xxx Xxxxxxxxx, PsyD, LP as your providerbooklet that describes mental health services. If you elect to use your health insurance have questions about the coverage, call your plan administrator. Of course I will provide you should with whatever information I can based on my experience and will be aware that most insurance companies require that I provide them with your clinical diagnosis and dates of services for billing purposes. Sometimes, insurance companies request additional clinical information, such as treatment plans, progress notes or summaries, or copies of happy to help you in understanding the entire records (in rare cases). 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 hands. You understand that, by using your insurance, you authorize me to release necessary information to receive from your insurance company. If it is necessary to clear confusion, I will try be willing to keep that information limited to call the minimum necessary. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. CANCELLED/MISSED APPOINTMENTS A scheduled appointment means that time is reserved only for you. If an appointment is missed or cancelled with less than 24-hours notice, you will be billed directly according to the scheduled fee or according to the rules of company on your insurance plan. Your insurance plan does not cover payment for missed appointments; therefore, you are responsible for payment in full. Repeated cancellations and missed appointments may result in termination of the therapeutic relationship. A letter reflecting termination will be mailed to you should this occurbehalf.

Billing and Payments. You will be expected to pay for each session appointment at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangementotherwise. I accept the following methods of payment: credit card, check, and cash. Checks should be made out to Xxxx Xxxxx, checksPh.D., Visa and MasterCardPLLC. In circumstances of unusual financial hardship, I may Late charges will be willing added to negotiate a fee adjustment or payment installment planaccounts with any balance over 30 days old. Accounts Late Fees are due 45 days after the date of service. Overdue accounts may be charged interest calculated at a rate of 1.52% per monthmonthly. If your account has not been paid for more than 60 days and arrangements for payment you have not been agreed uponarranged payment, I have the option of using legal means to secure the payment. This may involve hiring a , including collection agency agencies or going through small claims court which will require me to disclose otherwise confidential informationclaims. In most collection situations, the only information I release released regarding a patientclient’s treatment is his/her name, the nature of services provided, and the amount due. (If such legal action is necessary, its the costs will be included in the claim. .) INSURANCE REIMBURSEMENT There are many different insurance plans In order for us to set realistic treatment goals and reimbursement optionspriorities, and it is important to evaluate what resources you have available to pay for your treatment. I am not able an out-of-network provider for most insurance companies, but will provide you with a claim form and receipt of payment per your request. You will be required to keep track of them all. It is submit these forms to your responsibility to know your level of coverage insurance company for services with medirect reimbursement. I recommend all clients strongly encourage you to contact their your insurance company prior to ask about plan coverage, coservices to determine your out-pays, coof network benefits and for you to request pre-insurance, and deductibles, referencing Xxx Xxxxxxxxx, PsyD, LP as your providerauthorization if necessary. If you elect to use request reimbursement from your insurance carrier, your contract with your health insurance coverage, you should be aware that most insurance companies require carrier requires that I provide them with your information relevant to the services that I provide to you. I am required to provide a clinical diagnosis and dates of services for billing purposesa service code. Sometimes, insurance companies request Sometimes I am required to provide additional clinical information, information such as treatment plans, progress notes or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the entire records (in rare cases)minimum information about you that is necessary for the purpose requested. Although This information will become part of the insurance company files and will most likely be stored electronically. 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. You understand thatIn some cases, by using your insurance, you authorize me to release necessary they may share the information to your insurance companywith a national medical information databank. I will try to keep that information limited to the minimum necessaryprovide you with a copy of any report I submit per your request. It is important to remember that you always have the right to pay for Should my services yourself to avoid the problems described above. CANCELLED/MISSED APPOINTMENTS A scheduled appointment means that time is reserved only for you. If an appointment is missed or cancelled involvement with less than 24-hours noticeyour insurance company regarding pre- authorization exceed 15 minutes, you will be billed directly according required to pay for the scheduled fee or according to the rules time at a rate of your insurance plan. Your insurance plan does not cover payment for missed appointments; therefore, you are responsible for payment in full. Repeated cancellations and missed appointments may result in termination of the therapeutic relationship. A letter reflecting termination will be mailed to you should this occur$55 per 15 minute increment.

Billing and Payments. You will be expected to pay for each session at the time it is held, unless we agree otherwise otherwise, or unless you have insurance coverage that requires another arrangement. I accept cash, checks, Visa and MasterCard. In circumstances of unusual financial hardship, I may Payment schedules for other professional services will be willing agreed to negotiate a fee adjustment or payment installment plan. Accounts when they are due 45 days after the date of service. Overdue accounts may be charged interest at a rate of 1.5% per month. 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 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 '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. .] INSURANCE REIMBURSEMENT There 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 assistance I can in helping you receive the benefits to which you are many different entitled; however, you (not your insurance plans and reimbursement options, and I am not able to keep track company) are responsible for full payment of them allmy fees. It is very important that you find out exactly what mental health services your responsibility to know insurance policy covers. You should carefully read the section in your level of insurance coverage for booklet that describes mental health services You should also be aware that your contract with me. I recommend all clients contact their insurance company to ask about plan coverage, co-pays, co-insurance, and deductibles, referencing Xxx Xxxxxxxxx, PsyD, LP as your provider. If you elect to use your health insurance coverage, you should be aware that most insurance companies require company requires that I provide them it with your information relevant to the services that I provide to you. I am required to provide a clinical diagnosis and dates of services for billing purposesdiagnosis. Sometimes, insurance companies request Sometimes I am required to provide additional clinical information, information such as treatment plans, progress notes plans or summaries, or copies of the your entire records (in rare cases)Clinical Record. Although all insurance companies claim to keep In such information confidentialsituations, I have no control over what they do with it once it will make every effort to release only the minimum information about you that is in their handsnecessary for the purpose requested. You understand that, by using your insuranceBy signing "The Acknowledgement Notice", you authorize me to release necessary agree that I can provide requested information to your insurance company. I will try to keep that information limited to the minimum necessary. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. CANCELLED/MISSED APPOINTMENTS A scheduled appointment means that time is reserved only for you. If an appointment is missed or cancelled with less than 24-hours notice, you will be billed directly according to the scheduled fee or according to the rules of your insurance plan. Your insurance plan does not cover payment for missed appointments; therefore, you are responsible for payment in full. Repeated cancellations and missed appointments may result in termination of the therapeutic relationship. A letter reflecting termination will be mailed to you should this occurcarrier.

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. a payer source for which I accept cash, checks, Visa and MasterCard. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. Accounts are due 45 days after the date of service. Overdue accounts may be charged interest at a rate of 1.5% per montham an enrolled provider. If your account has not been paid for more than 60 days and arrangements for or 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. Should you fall more than two sessions behind in payment we will need to develop a plan to bring your account up to date. There will be a $25.00 charge for returned checks. INSURANCE REIMBURSEMENT There If you have a health insurance policy, it usually will not provide coverage for developmental speech-language therapy services. Thus I currently am a Medicaid and Part C (Early Steps) provider only. I will, provide forms for reimbursement and provide you with whatever assistance I can in helping you receive the benefits to which you are many different entitled; however, my office will not file insurance plans and reimbursement optionsfor you. Please be aware that you, and I am (not able to keep track your insurance company) are responsible for full payment of them allmy fees. It is your responsibility to know find out exactly what speech services your level of coverage for services with me. I recommend all clients contact their insurance company to ask about plan coverage, co-pays, co-insurance, and deductibles, referencing Xxx Xxxxxxxxx, PsyD, LP as your providerpolicy covers. If you elect have questions about the coverage, call your plan administrator. If you plan to use utilize insurance benefits, please complete the top portion of the HCFA-1500 form. If fees expected from your insurance company are denied, please recognize that the insurance contract is between the beneficiary and the insurance provider. You should also be aware that your contract with your health insurance coverage, you should be aware that most insurance companies company may require that I provide them it with your information relevant to services that I provide to you should you utilize these benefits. I am required to provide a clinical diagnosis and dates of services for billing purposesdiagnosis. Sometimes, insurance companies request Sometimes I am required to provide additional clinical information, information such as treatment plans, progress notes plans or summaries, or copies of your entire clinical record. In such situations, I will make every effort to release only the entire records (minimum information about you and your child that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in rare cases)a computer. Although 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. You understand thatI will provide you with a copy of any report I submit, by using your insuranceif you request it. By signing this Agreement, you authorize me to release necessary agree that I can provide requested information to your insurance companycarrier. I will try to keep that information limited to the minimum necessaryYOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THE INFORMATION IN THIS DOCUMENT AND AGREE TO ABIDE BY ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. CANCELLED/MISSED APPOINTMENTS A scheduled appointment means that time is reserved only for you. If an appointment is missed or cancelled with less than 24-hours notice, you will be billed directly according to the scheduled fee or according to the rules of your insurance plan. Your insurance plan does not cover payment for missed appointments; therefore, you are responsible for payment in full. Repeated cancellations and missed appointments may result in termination of the therapeutic relationship. A letter reflecting termination will be mailed to you should this occurYOUR SIGNATURE ALSO SERVES AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE.