Common use of Insurance Reimbursement Clause in Contracts

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. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurance, our office will gladly fill out a bill that will enable you to submit to current insurance carrier. Once you receive the claim forms from your insurance carrier you mail the bill I provided along with the claim form to your insurance company, who in turn, should mail you a check. We strongly recommend researching details about your mental health coverage. If you have a secondary health insurance company, you’ll need to find out that coverage and the interactions with the first coverage. It’s helpful to find out specifics of your mental health coverage with your insurance company by asking questions such as: Is there a deductible? How many visits per year are covered? What are the dates of the benefit year? Which services are covered (e.g., couples therapy, group therapy)? You should also be aware that your contract with your health insurance company requires that this office provide it with information relevant to the services that your therapist provides to you, including a clinical diagnosis. Sometimes your therapist is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, your therapist will make every effort to release only the information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, your therapist has no control over what they do with it. In some cases, they may share the information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, will provide you with a copy of any report submitted, if you request it. By signing this Agreement, you agree that your therapist can provide requested information to your insurance. Your therapist, Xxxxx Xxxxxxxxx, will gladly provide whatever assistance she can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of this practice’s fees. Also, please note that you always have the right to pay for your services without seeking insurance reimbursement in order to avoid the problems described above (unless prohibited by contract).

Insurance Reimbursement. In order for us you to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurancehave a health insurance policy, our office it will gladly usually provide some coverage for mental health treatment. Your provider will fill out a bill that will enable required forms and provide you with assistance in receiving the benefits to submit to current insurance carrier. Once which you receive the claim forms from your insurance carrier are entitled; however, you mail the bill I provided along with the claim form to (not your insurance company, who in turn, should mail ) are responsible for full payment of your xxxx. It is very important that you a check. We strongly recommend researching details about your find out exactly what mental health coverageservices your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have a secondary health questions about the coverage, call your plan administrator. Our office will provide you with any information we have based on our experience and will be happy to help you in understanding the information you receive from your insurance company, you’ll need . If your failure to find out that coverage and the interactions with the first coverage. It’s helpful to find out specifics of your mental health coverage comply with your insurance company by asking questions such as: Is there a deductible? How many visits per year are covered? What are company’s requirements regarding choice of providers, authorizations, or other issues results in the dates denial of the benefit year? Which services are covered (e.g.claims, couples therapyyou will be responsible for paying in full. If your coverage changes, group therapy)? it is your responsibility to notify our office and to comply with your new policy. You should also be aware that your contract with your health insurance company requires that this office we provide it with a clinical diagnosis and information relevant to about the services that your therapist provides provided to you, including a clinical diagnosis. Sometimes your therapist is required to provider must provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, your therapist will make every effort will be made to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, your therapist has we have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, You will provide you be provided with a copy of any report submitted, submitted if you request it. By signing the appropriate section of this Agreement, you agree that your therapist can provide to the provision of requested information to your carrier. If you need to file your own insurance, you may use either your statement or your encounter form. Your therapistPlease remember to include your policy information. Once we have all of the information about your insurance coverage, Xxxxx Xxxxxxxxx, your provider will gladly provide whatever assistance she discuss what you can in helping you receive expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to which you are entitled; however, you (not end your insurance company) are responsible for full payment of this practice’s feessessions. Also, please note It is important to remember that you always have the right to pay for your services without seeking insurance reimbursement in order yourself to avoid the problems described above ([unless this is prohibited by contract)].

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. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurance, our office will gladly fill out a bill that will enable you to submit to current insurance carrier. Once you receive the claim forms from your insurance carrier you mail the bill I provided along with the claim form to your insurance company, who in turn, should mail you a check. We strongly recommend researching details about your mental health coverage. If you have a secondary health insurance companypolicy, you’ll need it will usually provide some to find full coverage for a Psychological Evaluation. We will fill out that coverage forms and the interactions with the first coverage. It’s helpful to find out specifics of your mental health coverage with your insurance company by asking questions such as: Is there a deductible? How many visits per year are covered? What are the dates of the benefit year? Which services are covered (e.g., couples therapy, group therapy)? You should also be aware that your contract with your health insurance company requires that this office provide it with information relevant to the services that your therapist provides to you, including a clinical diagnosis. Sometimes your therapist is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, your therapist will make every effort to release only the information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, your therapist has no control over what they do with it. In some cases, they may share the information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, will provide you with a copy of any report submitted, if you request it. By signing this Agreement, you agree that your therapist can provide requested information to your insurance. Your therapist, Xxxxx Xxxxxxxxx, will gladly provide whatever assistance she we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of this practice’s our fees. AlsoIt is very important that we find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about coverage, please note call your plan administrator. We will provide you with whatever information we can based on our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, we will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. Managed health care plans such as HMO’s and PPO’s often require authorization before they provide reimbursement for mental health services. These plans are often limit coverage for psychological evaluations. Some clients feel that they need more services after insurance bene­fits end. Some managed care plans will not allow me to provide services to you once your benefits end. If this is the case, we will do our best to find another provider who will help you continue your needs. You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes we 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 and will proba­bly be stored in a computer. Though all insurance companies claim to keep such information confidential, we 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. We will provide you with a copy of any report we submit if you request it. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available. It is important to remember that you always have the right to pay for your our services without seeking insurance reimbursement in order yourself to avoid the problems described above ([unless prohibited by contract)].

Insurance Reimbursement. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have are available to pay for your treatment. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurancehave a health benefits policy, our office it will gladly fill out a bill that will enable you to submit to current insurance carrierusually provide some coverage for mental health treatment. Once you receive You are responsible for any portion of the claim forms from fees not covered by your insurance carrier you mail the bill I provided along with the claim form company. The general process is as follows: You pay your copay at time of session, your services are submitted to your insurance company, who and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursed. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember that we try to work with insurance companies as a courtesy to you. We will follow up on claims for services rejected by your insurance company only three times. After three rejections, you will be responsible for payment in turnfull. At that time, should mail we will provide you with a superbill if you choose to continue to pursue reimbursement by your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a checkgood idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. We strongly recommend researching details about YOU are responsible for reviewing your insurance policy statements and Explanation of Benefits. You should carefully read the section in your insurance coverage booklet that describes mental health coverageservices. If you have a secondary health insurance companyquestions, you’ll need to find out that coverage you should call your plan and inquire. The number for this inquiry is usually noted on the interactions with the first coverage. It’s helpful to find out specifics back of your insurance card at the bottom. Of course, we will provide you with whatever information we can, based on our experience and will be happy to try to assist you in deciphering the information you receive from your carrier. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before they will provide reimbursement for mental health coverage services. These plans are often oriented towards a short-term treatment approach, designed to resolve specific problems that are interfering with your insurance company by asking questions such as: Is there one’s usual level of functioning. It may be necessary to seek additional approval after a deductible? How certain number of sessions. In our experience, while quite a lot can be accomplished in short term therapy, many visits per year are covered? What are the dates of the benefit year? Which patients feel that more services are covered (e.g., couples therapy, group therapy)? necessary after insurance benefits expire. You should also be aware that your contract with your health insurance company requires that this office agreements may require you to authorize us to provide it with information relevant to the services that your therapist provides to you, including a clinical diagnosis. Sometimes your therapist is required to provide , and sometimes additional clinical information such as a treatment plans plan or summariessummary, or copies in rare cases, a copy of your the entire Clinical Record. In such situations, your therapist will make every effort to release only the information about you that is necessary for the purpose requestedrecord. This information will become part of the insurance company files files, and in all probability, some of it will probably be stored in a computercomputerized. Though all All insurance companies claim to keep such information confidential, your therapist has but once it is in their hands, we have no control over what they do with it. In some cases, they may share the information with a national medical information databankdata bank. Your therapistOnce we have all of the information about your insurance coverage, Xxxxx Xxxxxxxxx, we will provide you discuss what we can expect to accomplish with a copy of any report submitted, if you request it. By signing this Agreement, you agree that your therapist can provide requested information to your insurance. Your therapist, Xxxxx Xxxxxxxxx, will gladly provide whatever assistance she can in helping you receive the benefits that are available and what will happen if the insurance benefits run out before you feel ready to which you are entitled; however, you (not your insurance company) are responsible for full payment of this practice’s feesend our sessions. Also, please note It is important to remember that you always have the right to pay for your my services without seeking insurance reimbursement in order to yourself and avoid the problems complexities that are described above (unless prohibited by contract)above. Please note: Insurance rarely covers forensic psychology services.

Insurance Reimbursement. In order for us you to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurancehave a health insurance policy, our office it will gladly usually provide some coverage for mental health treatment. Your provider will fill out a bill that will enable required forms and provide you with assistance in receiving the benefits to submit to current insurance carrier. Once which you receive the claim forms from your insurance carrier are entitled; however, you mail the bill I provided along with the claim form to (not your insurance company, who in turn, should mail ) are responsible for full payment of your bill. It is very important that you a check. We strongly recommend researching details about your find out exactly what mental health coverageservices your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have a secondary health questions about the coverage, call your plan administrator. Our office will provide you with any information we have based on our experience and will be happy to help you in understanding the information you receive from your insurance company, you’ll need . If your failure to find out that coverage and the interactions with the first coverage. It’s helpful to find out specifics of your mental health coverage comply with your insurance company by asking questions such as: Is there a deductible? How many visits per year are covered? What are company’s requirements regarding choice of providers, authorizations, or other issues results in the dates denial of the benefit year? Which services are covered (e.g.claims, couples therapyyou will be responsible for paying in full. If your coverage changes, group therapy)? it is your responsibility to notify our office and to comply with your new policy. You should also be aware that your contract with your health insurance company requires that this office we provide it with a clinical diagnosis and information relevant to about the services that your therapist provides provided to you, including a clinical diagnosis. Sometimes your therapist is required to provider must provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, your therapist will make every effort will be made to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, your therapist has we have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, You will provide you be provided with a copy of any report submitted, submitted if you request it. By signing the appropriate section of this Agreement, you agree that your therapist can provide to the provision of requested information to your carrier. If you need to file your own insurance, you may use either your statement or your encounter form. Your therapistPlease remember to include your policy information. Once we have all of the information about your insurance coverage, Xxxxx Xxxxxxxxx, your provider will gladly provide whatever assistance she discuss what you can in helping you receive expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to which you are entitled; however, you (not end your insurance company) are responsible for full payment of this practice’s feessessions. Also, please note It is important to remember that you always have the right to pay for your services without seeking insurance reimbursement in order yourself to avoid the problems described above ([unless this is prohibited by contract)].

Insurance Reimbursement. In order for us If you plan to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. Please note that Xxxxx Xxxxxxxxx is an “Outuse out-of-Network" provider. If you choose to file insurancenetwork mental health coverage, our office I will gladly fill out a bill that will enable forms and provide you to submit to current insurance carrier. Once with whatever assistance I can in helping you receive the claim forms from your insurance carrier benefits to which you mail the bill I provided along with the claim form to are entitled; however, you (not your insurance company, who in turn, should mail ) are responsible for full payment of my fees. It is very important that you a check. We strongly recommend researching details about your find out exactly what mental health coverage. If you have a secondary health insurance company, you’ll need to find out that coverage and the interactions with the first coverage. It’s helpful to find out specifics of your mental health coverage with services your insurance company by asking questions such as: Is there a deductible? How many visits per year are covered? What are the dates of the benefit year? Which services are covered (e.g., couples therapy, group therapy)? policy covers. You should also be aware that your contract with your health insurance company requires that this office I provide it with information relevant to the services that your therapist provides I provide to you, including . Maryland permits me to send some information without your consent in order to file appropriate claims. I am required to provide them with a clinical diagnosis. Sometimes your therapist is I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, your therapist I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information Maryland law prevents insurers from making unreasonable demands for information, but there are no specific guidelines about what unreasonable includes. If I believe that your health insurance company is requesting an unreasonable amount of information, I will call it to your attention and we can discuss what to do. You can instruct me not to send requested information, but this could result in claims not being paid and an additional financial burden being placed on you. Once the insurance company has this information, it will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, your therapist has I have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, I will provide you with a copy of any report submittedI submit, if you request it. By signing this Agreement, you agree that your therapist I can provide requested information to your insurance. Your therapist, Xxxxx Xxxxxxxxx, will gladly provide whatever assistance she can in helping carrier if you receive the benefits choose to which you are entitled; however, you (not your insurance company) are responsible for full payment of this practice’s fees. Also, please note that you always have the right to pay for your services without seeking insurance reimbursement in order to avoid the problems described above (unless prohibited by contract)seek reimbursement.

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. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurancehave a health insurance policy, our office it will gladly usually provide some coverage for mental health treatment. We will fill out a bill that will enable forms and provide you to submit to current insurance carrier. Once with whatever assistance we can in helping you receive the claim forms from your insurance carrier benefits to which you mail the bill I provided along with the claim form to are entitled; however, you (not your insurance company, who in turn, should mail ) are responsible for full payment of our fees. It is very important that you a check. We strongly recommend researching details about your find out exactly what mental health coverageservices your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have a secondary health questions about the coverage, call your plan administrator. Of course, we will provide you with whatever information we can based on our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, you’ll need we will be willing to find out that coverage and call the interactions with company on your behalf. Due to the first coveragerising costs of health care, insurance benefits have increasingly become more complex. It’s helpful It is sometimes difficult to find out specifics of your determine exactly how much mental health coverage is available. "Managed Health Care" plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with your insurance company by asking questions such as: Is there a deductible? How many visits per year are covered? What are the dates person’s usual level of the benefit year? Which services are covered (e.g., couples 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, group therapy)? some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow us to provide services to you once your benefits end. If this is the case, we will do our best to find another provider who will help you continue your psychotherapy. You should also be aware that your contract with your health insurance company requires that this office we provide it with information relevant to the services that your therapist provides we provide to you, including . We are required to provide a clinical diagnosis. Sometimes your therapist is we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, your therapist will make every effort to release only the information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, your therapist has we have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, We will provide you with a copy of any report submittedwe submit, if you request it. By signing this Agreement, you agree that your therapist we can provide requested information to your insurancecarrier. Your therapistOnce we have all of the information about your insurance coverage, Xxxxx Xxxxxxxxx, we will gladly provide whatever assistance she discuss what we can in helping you receive expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to which you are entitled; however, you (not end your insurance company) are responsible for full payment of this practice’s feessessions. Also, please note It is important to remember that you always have the right to pay for your our services without seeking insurance reimbursement in order yourself to avoid the problems described above (unless prohibited by contract).

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. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurance, our office will gladly fill out a bill that will enable you to submit to current insurance carrier. Once you receive the claim forms from your insurance carrier you mail the bill I provided along with the claim form to your insurance company, who in turn, should mail you a check. We strongly recommend researching details about your mental health coverage. If you have a secondary health insurance companypolicy, you’ll need to find out that it will usually provide some coverage and the interactions with the first coverage. It’s helpful to find out specifics of your for mental health coverage treatment. I will facilitate your receipt of the benefits to which you are entitled including filling out forms and speaking with insurance representatives. You will be held responsible for full payment of our agreed upon fee should your insurance company by asking questions such as: Is there deny benefits or should your coverage lapse. Therefore, it is very important that you find out exactly what mental health benefits your insurance policy covers. Read your plan carefully and call your service representative if you have questions. Many insurance plans require advance authorization before they will provide reimbursement for mental health services. These plans often are oriented toward a deductible? How many visits short-term model and provide only a certain amount of sessions per year are covered? What are year. Many insurance companies may only authorize a few sessions at a time and I will need to periodically call them to authorize additional sessions. When I call to authorize treatment or continue our sessions, I will provide them with the dates minimum amount of the benefit year? Which services are covered (e.g.information needed, couples therapy, group therapy)? You should also be aware that your contract with your health insurance company requires that this office provide it with information relevant to the services that your therapist provides to you, usually including a clinical diagnosis. Sometimes your therapist is required to provide additional clinical information such as treatment plans or summaries, or copies goals for treatment, and a brief summary of your entire Clinical Recordcurrent functioning. In such situationsIt is possible, your therapist will make every effort to release only the information about you but very rare, that is necessary for the purpose requestedthey would require a copy of my clinical record. This information will become part of the insurance company files and will probably is likely to be stored in a computercomputerized. Though all All insurance companies claim to keep such information confidential, your therapist has but once it is in their hands, I have no control over what they do with it. In some cases, they may share the information with a national medical information databankdata bank. Your therapistBy signing this Agreement, Xxxxx Xxxxxxxxxyou agree that I can provide requested information to your insurance carrier. If you request it, I will provide you with a copy of any report submitted, if that I am asked to submit. I make it my policy to inform you request it. By signing this Agreement, you agree that your therapist can provide requested information to your insurance. Your therapist, Xxxxx Xxxxxxxxx, will gladly provide whatever assistance she can in helping you receive along the benefits to which you are entitled; however, you (not way of where we stand with your insurance company) are responsible company and what kind of information they have requested. Should insurance coverage end for full payment of some reason, we can discuss an out-of-pocket session fee. You can always choose to select this practice’s fees. Also, please note that you always option and have the right to pay for your my services without seeking insurance reimbursement in order yourself to avoid the problems described above complexities of the insurance industry. I am often not immediately available by telephone. To reach me, call (unless prohibited by contract)000) 000-0000. Leave a message in my confidential voicemail. Leave your name, phone number, and how I can reach you. Remove any call blocking devices until I return the call. I usually check my voice mail 1-2 times per day during the business week. I will make every effort to return your call the same day or the following business day. If we have difficulty reaching each other, please leave times when I can reach you and alternative phone numbers. You may send an email at xxxxxxxx@xxxxxxxxxxxxxxxxxxxx.xxx. If you are experiencing a clinical emergency or crisis and cannot reach me or wait for me to return your call, you should call your family physician, psychiatrist, or Crisis Services at 251-7575 (a 24-hour crisis hot-line with counselors that can insure your safety or talk to you about the crisis) or 911.

Insurance Reimbursement. In order for us to set realistic treatment goals and priorities, it It is I important to evaluate what the resources you have available to pay for your treatment. Please note I am a “fee for service” provider and therefore am not on any insurance panel. Therefore, it is very important that Xxxxx Xxxxxxxxx is an you find out exactly what “Out-of-Network" providerout of network” mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If you choose to file insurancesubmit for reimbursement, our office I will gladly fill out a bill provide you with an invoice that will enable has the information you well need to submit to current insurance carrier. Once you receive complete the claim forms from your insurance carrier you mail the bill I provided along with the claim form to for your insurance company, who in turn, should mail you a check. We strongly recommend researching details about Please be aware that most insurance companies require your mental health coverageclinical diagnosis be included on any reimbursement form. If you have a secondary health insurance company, you’ll need to find out that coverage and the interactions with the first coverage. It’s helpful to find out specifics of your mental health coverage with Sometimes your insurance company by asking questions such as: Is there a deductible? How many visits per year are covered? What are the dates of the benefit year? Which services are covered (e.g., couples therapy, group therapy)? You should also be aware that your contract with your health insurance company requires that this office provide it with information relevant to the services that your therapist provides to you, including a clinical diagnosis. Sometimes your therapist is required to provide request I submit additional clinical information information, such as treatment plans plans, progress notes or summaries, or copies of your the entire Clinical Record. In such situations, your therapist will make every effort to release only the information about you that is necessary for the purpose requestedrecord (in rare cases). This information will become part xxx of the insurance company files and will probably be stored in a computerfiles. Though Although all insurance companies claim to keep such information confidential, your therapist has no I have not control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, I will provide you with a copy of any report submitted, records I submit if you request it. By signing this AgreementIt is important to remember that paying for services yourself, without the use of insurance, avoids the problems described above Modalities of services delivered are on based treatment goals developed from the diagnostic process. In general there are several principles that underlay the approach to treatment. I am often not available immediately by telephone. Though I am usually in the office between 9am and 9pm, I won’t answer the phone when I am with a patient. When I am unavailable, my telephone is answered by voicemail that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact if necessary LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by state law and/or HIPAA. But, there are some situations where I am permitted or required to disclose information without either your consent or Authorization: □ 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. Ordinarily, I will not tell you about these consultations unless I believe that it is important to our work together. □ If I believe a patient is threatening serous bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm himself/herself, I may be obligated to seek for him/her or to contact family members or others who can help provide protection. In a similar situation occurs on the course of our work together, I will attempt to fully discuss it with your before taking any action. □ In most legal proceedings, you agree that your therapist can provide requested information to your insurance. Your therapist, Xxxxx Xxxxxxxxx, will gladly provide whatever assistance she can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of this practice’s fees. Also, please note that you always have the right to pay for prevent me from providing any information about your services without seeking insurance reimbursement treatment In some legal proceedings a judge may order my testimony if he/she determines that the issues demand it, and I must comply with the court order. □ If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to avoid defend myself. □ If a patient uses health insurance HMO/PPO/EAP/MCO, disclosure of confidential information may be required by your health insurance carrier in order to process the problems described above (unless prohibited by contract)claims. I will provide only the minimum necessary information. I have no control or knowledge over what insurance companies do with information that is submitted. You must be aware that submitting a mental health invoice of reimbursement carries a certain amount of risk of confidentiality, privacy or future capacity to obtain health or life insurance. □ If I observe or have knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if an elder or dependent adult credibly reports that he or she has experienced behavior including an act or omission constituting physical abuse, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, the law requires that I report to the appropriate government agency. Once such a report is filed, I be may be required to provide additional information.

Insurance Reimbursement. In order for us to set realistic treatment goals and priorities, it It is very important to evaluate that you find out exactly what resources you have available to pay for your treatment. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurance, our office will gladly fill out a bill that will enable you to submit to current insurance carrier. Once you receive the claim forms from mental health services your insurance carrier you mail policy covers. You should carefully read the bill I provided along with the claim form to section in your insurance company, who in turn, should mail you a check. We strongly recommend researching details about your coverage booklet that describes mental health coverageservices. If you have a secondary health questions about the coverage, call your plan administrator. Of course, Caring Hearts Professional Counseling Services, LLC will provide you with whatever information we can base on our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, you’ll need Caring Hearts Professional Counseling Services, LLC will be willing to find out that coverage and call the interactions with the first coveragecompany on your behalf. It’s helpful to find out specifics of your mental health coverage with your insurance company by asking questions such as: Is there While a deductible? How many visits per year are covered? What are the dates of the benefit year? Which services are covered (e.g., couples lot can be accomplished in short-term therapy, group therapy)? some patients feel that they need more services after insurance benefits end. SoonerCare and other managed care agencies will not allow me to provide services to you once your benefits end. If this is the case, we will do our best to aid in finding another provider who will help you continue your psychotherapy. You should also be aware that your contract most insurance companies require you to authorize Caring Hearts Professional Counseling Services, LLC to provide them with your health insurance company requires that this office provide it with information relevant to the services that your therapist provides to you, including a clinical diagnosis. Sometimes your therapist is Often, agencies are required to provide additional clinical information such as treatment plans or summaries, or copies of your the entire Clinical Record. In such situations, your therapist will make every effort to release only the information about you that is necessary for the purpose requestedrecord (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, your therapist Caring Hearts Professional Counseling Services, LLC has no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, We will provide you with a copy of any report submitted, if you request it. By signing this AgreementOnce we have all the information about your insurance coverage, you agree that your therapist we will discuss what we can provide requested information expect to your insurance. Your therapist, Xxxxx Xxxxxxxxx, will gladly provide whatever assistance she can in helping you receive accomplish with the benefits that are available and what will happen if they run out before you feel ready to which you are entitled; however, you (not your insurance company) are responsible for full payment of this practice’s feesend our sessions. Also, please note It is important to remember that you always have the right to pay for your services without seeking insurance reimbursement in order yourself to avoid the problems described above ([unless prohibited by contract)].

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. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurancehave a health insurance policy, our office it will gladly usually provide some coverage for mental health treatment. I will fill out a bill that will enable forms and provide you to submit to current insurance carrier. Once with whatever assistance I can in helping you receive the claim forms from your insurance carrier benefits to which you mail the bill I provided along with the claim form to are entitled; however, you (not your insurance company, who in turn, should mail ) are responsible for full payment of my fees / contracted rate. It is very important that you a check. We strongly recommend researching details about your find out exactly what mental health coverageservices your insurance policy covers and receive the necessary authorizations prior to your first appointment. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have a secondary health questions about the coverage, call your plan administrator. Of course I will provide you with whatever information I can based on my experience. I will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, you’ll need I will be willing to find out that coverage and call the interactions with company on your behalf. Due to the first coveragerising costs of health care, insurance benefits have increasingly become more complex. It’s helpful It is sometimes difficult to find out specifics of your determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with your insurance company by asking questions such as: Is there a deductible? How many visits per year are covered? What are the dates person’s usual level of the benefit year? Which services are covered (e.g., couples functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, group therapy)? some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that your contract most insurance companies require you to authorize me to provide them with your health insurance company requires that this office provide it with information relevant to the services that your therapist provides to you, including a clinical diagnosis. Sometimes your therapist is required I have to provide additional clinical information such as treatment plans or summaries, or copies of your the entire Clinical Record. In such situations, your therapist will make every effort to release only the information about you that is necessary for the purpose requestedrecord (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, your therapist has I have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, I will provide you with a copy of any report submittedI submit, if you request it. By signing this Agreement, you agree that your therapist can provide requested information to your insurance. Your therapist, Xxxxx Xxxxxxxxx, will gladly provide whatever assistance she can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of this practice’s fees. Also, please note that you always have the right to pay for your services without seeking insurance reimbursement in order to avoid the problems described above (unless prohibited by contract)request.

Insurance Reimbursement. In order for us If you plan to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. Please note that Xxxxx Xxxxxxxxx is use an “Outout-of-Network" provider. If you choose to file insurance, our office will gladly fill out a bill that will enable you to submit to current insurance carrier. Once you receive the claim forms from your insurance carrier you mail the bill I provided along with the claim form to your insurance company, who in turn, should mail you a check. We strongly recommend researching details about your network mental health coverage. If you have a secondary health insurance company, you’ll need to find I will fill out that coverage forms and the interactions with the first coverage. It’s helpful to find out specifics of your mental health coverage with your insurance company by asking questions such as: Is there a deductible? How many visits per year are covered? What are the dates of the benefit year? Which services are covered (e.g., couples therapy, group therapy)? You should also be aware that your contract with your health insurance company requires that this office provide it with information relevant to the services that your therapist provides to you, including a clinical diagnosis. Sometimes your therapist is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, your therapist will make every effort to release only the information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, your therapist has no control over what they do with it. In some cases, they may share the information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, will provide you with a copy of any report submitted, if you request it. By signing this Agreement, you agree that your therapist can provide requested information to your insurance. Your therapist, Xxxxx Xxxxxxxxx, will gladly provide whatever assistance she I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of this practice’s my fees. Also, please note It is very important that you always have find out exactly what mental health services your insurance policy covers. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the right services that I provide to pay for you. Maryland/D.C. law permits me to send some information without your services without seeking insurance reimbursement consent in order to avoid file appropriate claims. I am required to provide them with a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire clinical record. In such situations, I will make every effort to release only the problems described above (unless prohibited by contract)minimum information about you that is necessary for the purpose requested. Maryland/D.C. law prevents insurers from making unreasonable demands for information, but there are no specific guidelines about what unreasonable includes. If I believe that your health insurance company is requesting an unreasonable amount of information, I will call it to your attention and we can discuss what to do. You can instruct me not to send requested information, but this could result in claims not being paid and an additional financial burden being placed on you. Once the insurance company has this information, it will become part of the insurance company files and will probably be stored on a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this agreement, you agree that I can provide requested information to your carriers if you chose to seek reimbursement.

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. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose have a health insurance policy, it will usually provide some coverage for mental health treatment. It is your responsibility to file insurance, our office will gladly fill find out a bill that will enable exactly what mental health services are covered for you to submit to current insurance carrier. Once you receive the claim forms from by your insurance carrier you mail the bill I provided along with the claim form policy, and whether treatment needs to your insurance company, who in turn, should mail you a check. We strongly recommend researching details about your mental health coveragebe pre-authorized. If you have a secondary health questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company, you’ll need to find out that coverage and the interactions with the first coverage. It’s helpful to find out specifics of your mental health coverage with your insurance company by asking questions such as: Is there a deductible? How many visits per year are covered? What are the dates of the benefit year? Which services are covered (e.g., couples therapy, group therapy)? You should also be aware that your contract most insurance companies require me to provide them with your health insurance company requires a code number that this office provide it with information relevant to the services that your therapist provides to you, including indicates a clinical diagnosis. Sometimes The insurance company will sometimes ask for more information including symptoms, diagnoses, degree of impairment, and my treatment methods. This will become part of your therapist permanent medical record. I will let you know if this situation should arise. Please understand that I have no control over how these records are handled at the insurance company. My policy is required to provide additional clinical only as much information such as treatment plans or summaries, or copies of the insurance company needs to pay your entire Clinical Record. In such situations, your therapist will make every effort to release only the information about you that is necessary for the purpose requestedbenefits. 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, your therapist has I have no control over what they do with itit once it is in their hands. In some cases, they may share Once you have the information about your insurance coverage, we will discuss what we can expect to accomplish with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, will provide you with a copy of any report submitted, if you request it. By signing this Agreement, you agree that your therapist can provide requested information to your insurance. Your therapist, Xxxxx Xxxxxxxxx, will gladly provide whatever assistance she can in helping you receive the benefits that are available, and what will happen if they run out before you feel ready to which you are entitled; however, you (not your insurance company) are responsible for full payment of this practice’s feesend our sessions. Also, please note It is important to remember that you always have the right to pay for your services without seeking insurance reimbursement in order yourself to avoid the problems described above (unless prohibited above. Please note that the insurance contract is between you and your insurance company and the responsibility for your fees is yours. Consequently, disputes concerning coverage must be resolved by contract)you with your insurance carrier. Further, even though payment may be sent from the insurance company directly to me, it is your responsibility for any balance not covered by your insurance. Unpaid bills may be turned over to a collection agency and/or an attorney and, if so, you will also be responsible for collection and/or legal costs.

Insurance Reimbursement. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurancehave a health insurance policy, our office it will gladly usually provide some coverage for mental health treatment. We will fill out a bill that will enable forms and provide you to submit to current insurance carrier. Once with whatever assistance we can in helping you receive the claim forms from your insurance carrier benefits to which you mail the bill I provided along with the claim form to are entitled; however, you (not your insurance company, who in turn, should mail ) are responsible for full payment of our fees. It is very important that you a check. We strongly recommend researching details about your find out exactly what mental health coverageservices your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have a secondary health questions about the coverage, call your plan administrator. Of course, we will provide you with whatever information we can based on our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, you’ll need we will be willing to find out that coverage and call the interactions with company on your behalf. Due to the first coveragerising costs of health care, insurance benefits have increasingly become more complex. It’s helpful It is sometimes difficult to find out specifics of your determine exactly how much mental health coverage is available. "Managed Health Care" plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with your insurance company by asking questions such as: Is there a deductible? How many visits per year are covered? What are the dates person's usual level of the benefit year? Which services are covered (e.g., couples 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, group therapy)? some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow your doctor to provide services to you once your benefits end. If this is the case, we will do our best to find another provider who will help you continue your psychotherapy. You should also be aware that your contract with your health insurance company requires that this office we provide it with information relevant to the services that your therapist provides provided to you, including . We are required to provide a clinical diagnosis. Sometimes your therapist is we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, your therapist we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, your therapist has we have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, We will provide you with a copy of any report submittedwe submit, if you request it. By signing this Agreement, you agree that your therapist we can provide requested information to your insurancecarrier. Your therapistOnce we have all of the information about your insurance coverage, Xxxxx Xxxxxxxxx, we will gladly provide whatever assistance she discuss what we can in helping you receive expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to which you are entitled; however, you (not end your insurance company) are responsible for full payment of this practice’s feessessions. Also, please note It is important to remember that you always have the right to pay for your our services without seeking insurance reimbursement in order yourself to avoid the problems described above above. The Texas Behavioral Health Executive Council (unless prohibited BHEC) investigates and prosecutes professional misconduct committed by contract)marriage and family therapists, professional counselor, psychologists, psychological associates, social workers, and licensed specialists in school psychology. Although not every complaint against or dispute with a licensee involves professional misconduct, the Executive Council will provide you with information about how to file a complaint. The Texas BHEC website is xxx.xxxx.xxxxx.xxx. You may also call 0-000-000-0000 for more information. This notice is provided in accordance with Rule 884.31 of the Texas Behavioral Health Executive Council located in the Xxxxxx X.X. Xxxx State Office Building at the following address: 0000 Xxxxxxxx Xxx., Xxx. 7.300, Austin, Texas 78701. If a credit or due balance exists on your account equal to $9.99 or less, and is more than 90 days old, the account will be automatically adjusted according to our small balance policy. If you are seen within the 90-day period, the small balance will either be credited to your account or requested at the time of service. Following the 90-day period, we will not issue any refunds or send statements for balances equal to $9.99 or less. The Health Insurance Portability and Accountability Act (HIPAA) outlines how protected personal information can be used and disclosed. HIPAA is a federal law that protects information collected and stored both in writing and electronically. Psychology Resources is a HIPAA compliant organization, and we take the protection of your personal health information very seriously. Please read and agree to the following notice, which describes how your medical information may be used and disclosed as well as how you can get access to this information.

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. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurancehave a health insurance policy, our office it will gladly usually provide some coverage for mental health treatment. I will fill out a bill that will enable forms and provide you to submit to current insurance carrier. Once with whatever assistance I can in helping you receive the claim forms from your insurance carrier benefits to which you mail the bill I provided along with the claim form to are entitled; however, you (not your insurance company, who in turn, should mail ) are responsible for full payment of my fees. It is very important that you a check. We strongly recommend researching details about your find out exactly what mental health coverageservices your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have a secondary health questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, you’ll need I will be willing to find out that coverage and call the interactions with company on your behalf. Due to the first coveragerising costs of health care, insurance benefits have increasingly become more complex. It’s helpful It is sometimes difficult to find out specifics of your determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with your insurance company by asking questions such as: Is there a deductible? How many visits per year are covered? What are the dates person’s usual level of the benefit year? Which services are covered (e.g., couples 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, group therapy)? some clients feel that they need more services after insurance benefits end. (Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that your contract with your health insurance company requires that this office I provide it with information relevant to the services that your therapist provides I provide to you, including . I am required to provide a clinical diagnosis. Sometimes your therapist is I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, your therapist I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, your therapist has I have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, I will provide you with a copy of any report submittedI submit, if you request it. By signing this Agreement, you agree that your therapist I can provide requested information to your insurancecarrier. Your therapistOnce we have all of the information about your insurance coverage, Xxxxx Xxxxxxxxx, we will gladly provide whatever assistance she discuss what we can in helping you receive expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to which you are entitled; however, you (not end your insurance company) are responsible for full payment of this practice’s feessessions. Also, please note It is important to remember that you always have the right to pay for your my services without seeking insurance reimbursement in order yourself to avoid the problems described above (unless prohibited by contract).. Client Name: Signature: Date: Parent Name: Signature: Date:

Insurance Reimbursement. In order for us to set realistic treatment goals and prioritiesIf you have a health insurance policy, it is important to evaluate what resources you have available to pay will usually provide some coverage for your mental health treatment. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If We will provide you choose to file insurance, our office will gladly fill out a bill that will enable you to submit to current insurance carrier. Once with whatever assistance we can in helping you receive the claim forms from your insurance carrier benefits to which you mail the bill I provided along with the claim form to are entitled; however, you (not your insurance company, who in turn, should mail ) are responsible for full payment of our fees. It is very important that you a check. We strongly recommend researching details about your find out exactly what mental health coverageservices your insurance policy covers. If we are not a provider for your specific insurance company, we will not be considered an “in network” provider; we will be considered an “out of network” provider. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course we will provide you with whatever information we can based on our experience. If it is necessary to reduce confusion, we will be willing to call the company on your behalf. If we are a secondary participating provider in your health insurance companyplan, you’ll need you have already given our administrative staff permission by phone to find out that coverage and the interactions with the first coverage. It’s helpful to find out specifics of your mental health coverage with contact your insurance company and verify your benefits. The payment you make at the visit, known as a “copayment,” is specified by asking questions such as: Is there a deductible? How many the insurance or managed care company. We are responsible for obtaining authorization for your visits per year are covered? What are the dates of the benefit year? Which services are covered (e.g., couples therapy, group therapy)? You should also be aware that your and for submitting insurance claims. Your contract with your health insurance company requires that this office provide it with we disclose information relevant to the services that your therapist provides we provide to you, including . We are required to provide a clinical diagnosis. Sometimes your therapist is we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, your therapist we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, your therapist has we have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, We will provide you with a copy of any report submittedwe submit, if you request it. By signing this Agreementthe Acknowledgement Sheet, you agree that your therapist we can provide requested information to your insurance. Your therapist, Xxxxx Xxxxxxxxx, will gladly provide whatever assistance she can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of this practice’s fees. Also, please note that you always have the right to pay for your services without seeking insurance reimbursement in order to avoid the problems described above (unless prohibited by contract).

Insurance Reimbursement. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have are available to pay for your treatment. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurance, our office will gladly fill out a bill that will enable you to submit to current insurance carrier. Once you receive the claim forms from your insurance carrier you mail the bill I provided along with the claim form to your insurance company, who in turn, should mail you a check. We strongly recommend researching details about your mental health coveragetherapy. If you have a secondary health benefits policy, it will usually provide some coverage for mental health treatment. I do not participate on any insurance panels and thus your treatment will likely be considered “out of network.” I will provide you with a receipt that includes the information insurance companies need to process your claim for reimbursement and you can opt to file your own claims. Remember that you, not your insurance company, you’ll need to find out that are responsible for full payment of my fees. Please read carefully the section in your insurance coverage booklet, which describes mental health services. If you have questions, you should call your plan and ask the interactions with insurance representative. I will, of course, provide whatever help I can in deciphering the first information you get from your carrier about your coverage. It’s helpful The rising cost of health care has resulted in an increasing level of complexity about insurance benefits that sometimes makes it difficult to find out specifics of your determine exactly how much mental health coverage with is available. "Managed Health Care Plans" such as HMOs and PPOs often require advance authorization before they will provide reimbursement for mental health services. If you are planning to use your insurance company by asking questions such as: Is there to help pay for therapy with me, you will want to ask your insurance representative if they cover my services. Many plans are oriented towards a deductible? How short-term treatment approach designed to resolve specific problems that might be interfering with one's usual level of functioning. It may be necessary to seek additional approval after a certain number of sessions. In my experience, while quite a lot can be accomplished in short-term therapy, many visits per year are covered? What are the dates of the benefit year? Which clients feel that more services are covered (e.g., couples therapy, group therapy)? necessary after insurance benefits expire. You should also be aware that most insurance agreements require you to authorize me to provide a diagnosis of mental illness. This diagnosis will become part of your contract with your health insurance company requires that this office provide it with information relevant to the services that your therapist provides to you, including a clinical diagnosispermanent medical record. Sometimes your therapist is required to provide additional clinical information such as a treatment plans plan or summariessummary, or copies or, in rare cases, a copy of your the entire Clinical Record. In such situations, your therapist will make every effort to release only the information about you that record is necessary for the purpose requestedalso required. This information will become part of the insurance company files and files, and, in all probability, some of it will probably be stored in a computercomputerized. Though all All insurance companies claim to keep such information confidential, your therapist has but once it is in their hands, I have no control over what they do with it. In some cases, cases they may share the information with a national medical information databankdata bank. Your therapistIf you request it, Xxxxx Xxxxxxxxx, I will provide you with a copy of any report submittedthat I submit to your insurance carrier. Please remember that you always have a choice to bypass the insurance altogether and pay a negotiated fee out of pocket. By signing this agreement you are giving me permission to release information requested by your carrier. I am required to keep appropriate records of the psychological services that I provide. Except in unusual circumstances that involve danger to yourself and/or others or the record makes reference to another person (unless the other person is a health care provider) and I believe the access is reasonably likely to cause substantial harm to such another person, you may examine or receive a copy of your Clinical record, if you request it. By signing this Agreement, you agree that your therapist can provide requested information to your insuranceit in writing. Your therapistClinical record includes information about your reasons for seeking therapy, Xxxxx Xxxxxxxxxa description of the ways in which the problem impacts your life, your diagnosis, the goals that we set for treatment, your progress on those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of professional consultations, your billing records, and any reports that have been sent to anyone, including your insurance carrier. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason I recommend that you allow me to provide you with a treatment summary instead, or in the case that you wish to review your entire Clinical record, that you do so in my presence or in the presence of another mental health professional, so that you can discuss the contents. You should be aware that this will gladly provide whatever assistance she can be treated in helping the same manner as any other professional service and you receive the benefits to which will be billed accordingly. If you are entitled; however, you (not your insurance company) are responsible for full payment under 18 years of this practice’s fees. Alsoage, please note be aware that you always have the law may provide your parents with the right to pay for examine your services without seeking insurance reimbursement in order treatment records. Normally, I will provide them only with general information on how your treatment is proceeding. If, however, I feel that there is a high risk that you will seriously harm yourself or another, I will notify them of my concern. Before giving them any information I will try to avoid discuss the problems described above (unless prohibited by contract)matter with you and will do the best I can to resolve any objections you might have about what I am prepared to discuss.

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. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurance, our office will gladly fill out a bill that will enable you to submit to current insurance carrier. Once you receive the claim forms from your insurance carrier you mail the bill I provided along with the claim form to your insurance company, who in turn, should mail you a check. We strongly recommend researching details about your mental health coverage. If you have a secondary health insurance companypolicy, you’ll need to find out that it will usually provide some coverage and the interactions with the first coverage. It’s helpful to find out specifics of your for mental health coverage with treatment. You will be held responsible for full payment of our agreed upon fee should your insurance company by asking questions such as: Is there deny benefits or should your coverage lapse. Therefore, it is very important that you find out exactly what mental health benefits your insurance policy covers. Read your plan carefully and call your service representative if you have questions. Many insurance plans require advance authorization before they will provide reimbursement for mental health services. These plans often are oriented toward a deductible? How many visits short-term model and provide only a certain amount of sessions per year are covered? What are year. Many insurance companies may only authorize a few sessions at a time and I will need to periodically call them to authorize additional sessions. When I call to authorize treatment or continue our sessions, I will provide them with the dates minimum amount of the benefit year? Which services are covered (e.g.information needed, couples therapy, group therapy)? You should also be aware that your contract with your health insurance company requires that this office provide it with information relevant to the services that your therapist provides to you, usually including a clinical diagnosis. Sometimes your therapist is required to provide additional clinical information such as treatment plans or summaries, or copies goals for treatment, and a brief summary of your entire Clinical Recordcurrent functioning. In such situationsIt is possible, your therapist will make every effort to release only the information about you but very rare, that is necessary for the purpose requestedthey would require a copy of my clinical record. This information will become part of the insurance company files and will probably is likely to be stored in a computercomputerized. Though all All insurance companies claim to keep such information confidential, your therapist has but once it is in their hands, I have no control over what they do with it. In some cases, they may share the information with a national medical information databankdata bank. Your therapistBy signing this Agreement, Xxxxx Xxxxxxxxxyou agree that I can provide requested information to your insurance carrier. If you request it, I will provide you with a copy of any report submitted, if that I am asked to submit. I make it my policy to inform you request it. By signing this Agreement, you agree that your therapist can provide requested information to your insurance. Your therapist, Xxxxx Xxxxxxxxx, will gladly provide whatever assistance she can in helping you receive along the benefits to which you are entitled; however, you (not way of where we stand with your insurance company) are responsible company and what kind of information they have requested. Should insurance coverage end for full payment of some reason, we can discuss an out-of-pocket session fee. You can always choose to select this practice’s fees. Also, please note that you always option and have the right to pay for your my services without seeking insurance reimbursement in order yourself to avoid the problems described above complexities of the insurance industry. I am only in the office on specific days. Since this is the case, I am often not immediately available by telephone. To reach me, call (000) 000-0000. Leave a message in my confidential voicemail. Leave your name, phone number, and how I can reach you. I usually check my voice mail 1-2 times per day during the business week. I will make every effort to return your call the same day or early the following business day. If we have difficulty reaching each other, please leave times when I can reach you and alternative phone numbers. If you are experiencing a clinical emergency call me directly. If I am available, I will call you back as soon as possible. If you are in crisis and cannot reach me or wait for me to return your call, you should call your family physician, psychiatrist, or Crisis Services at 834-3131 or Spectrum Cares at 882-4357 (a 24-hour crisis hot-line with counselors that can insure your safety or talk to you about the crisis). If I know that I will be out of town for an extended period of time, I will have another counselor designated to be on-call for me in crisis situations. If you feel that you might potentially utilize these crises options, please let me know during our session so that we can develop a comprehensive crisis plan. Both law and the standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in situations where you are a danger to yourself (or others) or where others have supplied information to me confidentially, you may examine and/or receive a copy of your Clinical Record. This request must be made in writing. Because they are professional records, they can be misinterpreted or upsetting to lay readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. If you would like me to copy your records for you, I will charge a copying fee of 75 cents per page. Please see attached New York Notice Form for a listing of your rights. New York law gives children of any age the right to independently consent to and receive mental health treatment without parental consent if they request it and if it is determined that such services are necessary and requiring parental consent would have a detrimental effect on the course of the child’s treatment. Even where parental consent is given, children over the age of 12 have a right to control access to their treatment records. If you are age 13 or older, I will request an agreement from your parents that they consent to allow me to maintain your confidentiality. If they agree, I will provide them only with general information about our work together unless prohibited by contractI feel that there is a high risk that you will seriously harm yourself, harm another, or are in an abusive situation. In these situations, I will notify them of my concerns about your safety. If they request it, I will provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you (if possible), and will do the best I can to resolve any objections you may have about what I am prepared to discuss with your parents.

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. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurancehave a health insurance policy, our office it will gladly usually provide some coverage for mental health treatment. We will fill out a bill that will enable forms and provide you to submit to current insurance carrier. Once with whatever assistance we can in helping you receive the claim forms from your insurance carrier benefits to which you mail the bill I provided along with the claim form to are entitled; however, you (not your insurance company, who in turn, should mail ) are responsible for full payment of our fees. It is very important that you a check. We strongly recommend researching details about your find out exactly what mental health coverageservices your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have a secondary health questions about the coverage, call your plan administrator. Of course, we will provide you with whatever information we can based on our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, you’ll need we will be willing to find out that coverage and call the interactions with company on your behalf. Due to the first coveragerising costs of health care, insurance benefits have increasingly become more complex. It’s helpful It is sometimes difficult to find out specifics of your determine exactly how much mental health coverage is available. "Managed Health Care" plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with your insurance company by asking questions such as: Is there a deductible? How many visits per year are covered? What are the dates person’s usual level of the benefit year? Which services are covered (e.g., couples 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, group therapy)? some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow us to provide services to you once your benefits end. If this is the case, we will do our best to find another provider who will help you continue your psychotherapy. You should also be aware that your contract with your health insurance company requires that this office we provide it with information relevant to the services that your therapist provides we provide to you, including . We are required to provide a clinical diagnosis. Sometimes your therapist is we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, your therapist will make every effort to release only the information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, your therapist has we have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, We will provide you with a copy of any report submitted, we submit if you request it. By signing this Agreement, you agree that your therapist we can provide requested information to your insurancecarrier. Your therapistOnce we have all of the information about your insurance coverage, Xxxxx Xxxxxxxxx, we will gladly provide whatever assistance she discuss what we can in helping you receive expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to which you are entitled; however, you (not end your insurance company) are responsible for full payment of this practice’s feessessions. Also, please note It is important to remember that you always have the right to pay for your our services without seeking insurance reimbursement in order yourself to avoid the problems described above (unless prohibited by contract).

Insurance Reimbursement. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources re- sources you have available to pay for your treatment. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurancehave a health insurance policy, our office it will gladly fill out a bill that usually provide some coverage for mental health treatment. I will enable provide you to submit to current insurance carrier. Once with whatever as- sistance I can in helping you receive the claim forms from your insurance carrier benefits to which you mail the bill I provided along with the claim form to are entitled; however, you (not your insurance company, who in turn, should mail ) are responsible for full payment of therapy fees. It is very important that you a check. We strongly recommend researching details about your find out exactly what mental health coverageservices your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have a secondary health questions about the coverage, call your plan administrator. Of course I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is nec- xxxxxx to clear confusion, you’ll need I am willing to find out that coverage and call the interactions with company on your behalf. Due to the first coveragerising costs of health care, insurance benefits have increasingly become more complex. It’s helpful It is sometimes difficult to find out specifics of your determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with your insurance company by asking questions such as: Is there a deductible? How many visits per year are covered? What are the dates person’s usual level of the benefit year? Which services are covered (e.g., couples functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short- term therapy, group therapy)? some clients feel that they need more services after insurance benefits end. Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that your contract most insurance companies require you to authorize me to provide them with your health insurance company requires that this office provide it with information relevant to the services that your therapist provides to you, including a clinical diagnosis. Sometimes your therapist is required I have to provide additional clinical information such as treatment plans or summaries, or copies of your the entire Clinical Record. In such situations, your therapist will make every effort to release only the information about you that is necessary for the purpose requestedrecord (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, your therapist has I have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, I will provide you with a copy of any report submittedI submit, if you request it. By signing this AgreementOnce we have all of the information about your insurance coverage, you agree that your therapist we will discuss what we both can provide requested information expect to your insurance. Your therapist, Xxxxx Xxxxxxxxx, will gladly provide whatever assistance she can in helping you receive accomplish with the benefits that are available and what will happen if they run out before you feel ready to which you are entitled; however, you (not end your insurance company) are responsible for full payment of this practice’s feessessions. Also, please note It is important to remember that you always have the right to pay for your services without seeking insurance reimbursement in order yourself to avoid the problems described above (above, unless prohibited by contract). If I am out-of-network with your insurance company but have a PPO plan and you would like to use insurance coverage to pay for your therapy, I will provide you with a superbill. This superbill can then be submitted to your insurance company for reimbursement. Please be aware that if you choose to provide this receipt for services to your insurance company, it must include a psychi- atric diagnosis. In that event, I will inform you about the diagnosis that I plan to render before it is given. Any diagnosis that is made will become part of your permanent insurance records. A superbill is no guarantee of reimbursement. Even if you do not pursue reimbursement through your insurance company, a superbill may be useful for tax purposes or for utilizing funds set aside in an employer-based health savings account.

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. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurancehave a health insurance policy, our office it will gladly usually provide some coverage for mental health treatment. We will fill out a bill that will enable forms and provide you to submit to current insurance carrier. Once with whatever assistance we can in helping you receive the claim forms from your insurance carrier benefits to which you mail the bill I provided along with the claim form to are entitled; however, you (not your insurance company, who in turn, should mail ) are responsible for full payment of fees. It is very important that you a check. We strongly recommend researching details about your find out exactly what mental health coverageservices your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have a secondary health questions about the coverage, call your plan administrator. Of course, we will provide you with whatever information we can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, you’ll need we will be willing to find out that coverage and call the interactions with company on your behalf. Due to the first coveragerising costs of health care, insurance benefits have increasingly become more complex. It’s helpful It is sometimes difficult to find out specifics of your determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with your insurance company by asking questions such as: Is there a deductible? How many visits per year are covered? What are the dates person’s usual level of the benefit year? Which services are covered (e.g., couples 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, group therapy)? some clients feel that they need more services after insurance benefits end. Some managed-care plans will not allow us to provide services to you once your benefits end. If this is the case, we will do our best to find another provider who will help you continue your psychotherapy. You should also be aware that your contract with your health insurance company requires that this office we provide it with information relevant to the services that your therapist provides we provide to you, including . We are required to provide a clinical diagnosis. Sometimes your therapist is we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, your therapist we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, your therapist has we have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, We will provide you with a copy of any report submittedwe submit, if you request it. By signing this Agreement, you agree that your therapist RHEMA Counseling & Support Services, PC can provide requested information to your insurancecarrier. Your therapistOnce we have all of the information about your insurance coverage, Xxxxx Xxxxxxxxx, we will gladly provide whatever assistance she discuss what we can in helping you receive expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to which you are entitled; however, you (not end your insurance company) are responsible for full payment of this practice’s feessessions. Also, please note It is important to remember that you always have the right to pay for your services without seeking insurance reimbursement in order to avoid the problems described above (yourself unless prohibited by your health insurance contract).

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. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurance, our office will gladly fill out a bill that will enable you to submit to current insurance carrier. Once you receive the claim forms from your insurance carrier you mail the bill I provided along with the claim form to your insurance company, who in turn, should mail you a check. We strongly recommend researching details about your mental health coverage. If you have a secondary health insurance companypolicy, you’ll need to find out that it will usually provide some coverage and the interactions with the first coverage. It’s helpful to find out specifics of your for mental health coverage with your insurance company by asking questions such as: Is there a deductible? How many visits per year are covered? What are the dates of the benefit year? Which services are covered (e.g., couples therapy, group therapy)? You should also be aware that your contract with your health insurance company requires that this office provide it with information relevant to the services that your therapist provides to you, including a clinical diagnosistreatment. Sometimes your therapist is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, your therapist I will make every effort to release only the information about you that is necessary for the purpose requested. This information will become part of the insurance company files fill out forms and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, your therapist has no control over what they do with it. In some cases, they may share the information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, will provide you with a copy of any report submitted, if you request it. By signing this Agreement, you agree that your therapist can provide requested information to your insurance. Your therapist, Xxxxx Xxxxxxxxx, will gladly provide whatever assistance she I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees, It is very important that you find out exactly what mental health services your insurance policy covers. You should also be aware that 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). Be aware that you may have authorized this practice’s feesrelease of information from your insurance company when you signed up for benefits from them. AlsoIn such situations, please note I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company file. 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 data bank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for your my services without seeking insurance reimbursement in order yourself to avoid the problems described above (above, unless prohibited by contract). I am often not immediately available by telephone. While I am usually in my office between 9 a.m. and 5:00 p.m. during the week, I will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by an voicemail that I monitor frequently. If you are unable to reach me and feel that you can’t wait for me to return you call, contact Siskiyou County Mental Health at 800-842-8979 or 911. You may also go to any emergency room for help. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.

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. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurance, our office will gladly fill out a bill that will enable you to submit to current insurance carrier. Once you receive the claim forms from your insurance carrier you mail the bill I provided along with the claim form to your insurance company, who in turn, should mail you a check. We strongly recommend researching details about your mental health coverage. If you have a secondary health insurance policy, it usually will provide some coverage for mental health treatment. I will provide you with whatever assistance I can in facilitating your receipt of the benefits you are entitled to receive. However, my relationship is with you, not your insurance company, you’ll need to . You are responsible for fees for service. It is important that you find out that coverage and the interactions with the first coverage. It’s helpful to find out specifics of your mental health coverage with exactly what services your insurance company by asking questions such aspolicy does and does not cover. You should carefully read the information in your insurance coverage booklet. I will attempt to help you clarify insurance requirements and benefits information. With your consent, I will provide your insurance carrier with information that is necessary and appropriate in order to obtain maximum benefits. Some other points to keep in mind about health insurance include: Is there a deductible? How many visits per year are covered? What are • Some insurance requires pre-authorization. It is the client’s responsibility to obtain pre-authorization for services before the initial visit. It is important to note that most companies do not backdate authorizations. Therefore, if this step is forgotten, the client is liable for charges. I can not resubmit claims for dates of the benefit year? Which services service prior to authorization, if preauthorization is required. • Insurance policies have limits on payment. Health care plans such as HMO’s and PPO’s are covered (e.g.often oriented toward short-term treatment approaches designed to resolve specific problems that interfere with functioning. Insurance may not pay for all types of services. If pre-authorization is required for payment, couples it is necessary to receive additional approval from insurance to continue after a certain number of sessions. While a lot can be accomplished in short-term therapy, group therapy)? You should also be aware that your many clients want or need services beyond those covered by their health insurance benefits. • Your contract with your health insurance company requires that this office I provide it with information relevant to the services that your therapist provides I provide for you. I am required to you, including provide a clinical diagnosis. Sometimes your therapist is required to As previously addressed, most managed care companies require that I provide additional clinical information such as treatment plans or summaries, summaries or copies of your entire Clinical Recordclinical record. In such situations, your therapist I will make every effort efforts to release only the minimum information about you that is necessary for the purpose requested. This • When we have information about your insurance coverage, we will become part of discuss what we can expect to accomplish with these benefits and what will happen if they run out before you feel ready to end your sessions. It is important to remember you have the right to self-pay. I file insurance claims as a courtesy to my clients. However all charges are the client’s responsibility. Working with your insurance company files is a cooperative effort. Often it takes your calls to insurance representatives to make sure that claims are paid correctly and will probably be stored in a computertimely manner. Though all insurance companies claim to keep such information confidential, your therapist has no control over what they do with it. In some cases, they may share the information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, will provide It is also important that you with a copy notify me of any report submitted, if you request itchanges in your policy. By signing this Agreement, you agree that your therapist can provide requested information It is important to your insurance. Your therapist, Xxxxx Xxxxxxxxx, will gladly provide whatever assistance she can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of this practice’s fees. Also, please note remember that you always have the right to pay for my services yourself and avoid problems with insurance described above. This is really the only way to assure confidentiality and control over psychotherapy services. If you choose this option, I will discuss plans that can make this financially affordable. I appreciate the opportunity to be of profession service to you. I look forward to your services without seeking insurance reimbursement in order questions and comments at any time. If you are satisfied with my services, I would appreciate you referring other people to avoid the problems described above (unless prohibited by contract)me who might benefit from these services. My practice grows from your referrals.

Insurance Reimbursement. In order for us If you plan to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. Please note that Xxxxx Xxxxxxxxx is an “Outuse out-of-Network" provider. If you choose to file insurancenetwork mental health coverage, our office we will gladly fill out a bill that will enable any necessary forms required of your insurance and provide you to submit to current insurance carrier. Once with whatever assistance we can in helping you receive the claim forms from benefits to which you are entitled. However, you (and not your insurance carrier provider) are responsible for full payment of our fees at the end of each session. Our session fee is $170/session. Your insurance will then reimburse you mail the bill I provided along with the claim form to if they cover your insurance company, who in turn, should mail you a checksessions. We strongly recommend researching details about It is your mental health coverage. If you have a secondary health insurance company, you’ll need responsibility to find out that coverage and the interactions with the first coverage. It’s helpful to find out specifics of your exactly what mental health coverage with services your insurance company by asking questions such as: Is there a deductible? How many visits per year are covered? What are the dates of the benefit year? Which services are covered (e.g., couples therapy, group therapy)? policy covers. You should also be aware that your contract with your health insurance company requires that this office we provide it with information relevant to the services that your therapist provides provided to you, including . We are required to provide a clinical diagnosis. Sometimes your therapist is we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, your therapist we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, your therapist has we have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, We will provide you with a copy of any report submittedwe submit, if you request it. By signing this Agreement, you agree that your therapist we can provide requested information to your insurancecarrier. Your therapistOnce we have all of the information about your insurance coverage, Xxxxx Xxxxxxxxx, we will gladly provide whatever assistance she discuss what we can in helping you receive expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to which you are entitled; however, you (not end your insurance company) are responsible for full payment of this practice’s feessessions. Also, please note It is important to remember that you always have the right to pay for your our services without seeking insurance reimbursement in order yourself to avoid the problems described above above. HIPAA (unless prohibited by contract)Health Insurance Portability and Accountability Act) provides you with several new or expanded rights with regard to your clinical records and disclosures of protected health information. These rights include requesting that your doctor amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and our privacy policies and procedures.

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. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurance, our office will gladly fill out a bill that will enable you to submit to current insurance carrier. Once you receive the claim forms from your insurance carrier you mail the bill I provided along with the claim form to your insurance company, who in turn, should mail you a check. We strongly recommend researching details about your mental health coverage. If you have a secondary health insurance companypolicy, you’ll need to find out that it will usually provide some coverage and the interactions with the first coverage. It’s helpful to find out specifics of your for mental health coverage with your insurance company by asking questions such as: Is there a deductible? How many visits per year are covered? What are the dates of the benefit year? Which services are covered (e.g., couples therapy, group therapy)? You should also be aware that your contract with your health insurance company requires that this office provide it with information relevant to the services that your therapist provides to you, including a clinical diagnosistreatment. Sometimes your therapist is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical RecordXx. In such situations, your therapist will make every effort to release only the information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, your therapist has no control over what they do with it. In some cases, they may share the information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, Xxxxxxx will provide you with a copy of any report submitted, if you request it. By signing this Agreement, you agree that your therapist can provide requested information to your insurance. Your therapist, Xxxxx Xxxxxxxxx, will gladly provide whatever assistance she he can in helping you receive the benefits to which you are entitled; however, you (you, not your insurance company) , are responsible for full payment of this practice’s fees. AlsoIt is very important that you find out about mental health services your insurance policy covers. If you have questions about the coverage, please note call your plan administrator. We will provide you with whatever information we can and will call the company on your behalf to clear up any confusion. Due to the rising cost of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. Some plans require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits end. Some plans will not allow your therapist to provide services to you once your benefits cease. If this is the case, we will do our best to find another provider who will help you continue your psychotherapy. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for your our services without seeking insurance reimbursement in order yourself to avoid the problems described above ([unless prohibited by contract)].

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. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurance, our office will gladly fill out a bill that will enable you to submit to current insurance carrier. Once you receive the claim forms from your insurance carrier you mail the bill I provided along with the claim form to your insurance company, who in turn, should mail you a check. We strongly recommend researching details about your mental health coverage. If you have a secondary health insurance companypolicy, you’ll need to find out that it will usually provide some coverage and the interactions with the first coverage. It’s helpful to find out specifics of your for mental health coverage with treatment. You will be held responsible for full payment of our agreed upon fee should your insurance company by asking questions such as: Is there deny benefits or should your coverage lapse. Therefore, it is very important that you find out exactly what mental health benefits your insurance policy covers. Read your plan carefully and call your service representative if you have questions. Many insurance plans require advance authorization before they will provide reimbursement for mental health services. These plans often are oriented toward a deductible? How many visits short-term model and provide only a certain amount of sessions per year are covered? What are year. Many insurance companies may only authorize a few sessions at a time and I will need to periodically call them to authorize additional sessions. When I call to authorize treatment or continue our sessions, I will provide them with the dates minimum amount of the benefit year? Which services are covered (e.g.information needed, couples therapy, group therapy)? You should also be aware that your contract with your health insurance company requires that this office provide it with information relevant to the services that your therapist provides to you, usually including a clinical diagnosis. Sometimes your therapist is required to provide additional clinical information such as treatment plans or summaries, or copies goals for treatment, and a brief summary of your entire Clinical Recordcurrent functioning. In such situationsIt is possible, your therapist will make every effort to release only the information about you but very rare, that is necessary for the purpose requestedthey would require a copy of my clinical record. This information will become part of the insurance company files and will probably is likely to be stored in a computercomputerized. Though all All insurance companies claim to keep such information confidential, your therapist has but once it is in their hands, I have no control over what they do with it. In some cases, they may share the information with a national medical information databankdata bank. Your therapistBy signing this Agreement, Xxxxx Xxxxxxxxxyou agree that I can provide requested information to your insurance carrier. If you request it, I will provide you with a copy of any report submitted, if that I am asked to submit. I make it my policy to inform you request it. By signing this Agreement, you agree that your therapist can provide requested information to your insurance. Your therapist, Xxxxx Xxxxxxxxx, will gladly provide whatever assistance she can in helping you receive along the benefits to which you are entitled; however, you (not way of where we stand with your insurance company) are responsible company and what kind of information they have requested. Should insurance coverage end for full payment of some reason, we can discuss an out-of-pocket session fee. You can always choose to select this practice’s fees. Also, please note that you always option and have the right to pay for your my services without seeking insurance reimbursement in order yourself to avoid the problems described above complexities of the insurance industry. I am only in the office on specific days. Since this is the case, I am often not immediately available by telephone. To reach me, call (000) 000-0000. Leave a message in my confidential voicemail. Leave your name, phone number, and how I can reach you. I usually check my voice mail 1-2 times per day during the business week. I will make every effort to return your call the same day or early the following business day. If we have difficulty reaching each other, please leave times when I can reach you and alternative phone numbers. Please be aware that I am NOT able to receive text messages. If you are experiencing a clinical emergency call me directly. If I am available, I will call you back as soon as possible. If you are in crisis and cannot reach me or wait for me to return your call, you should call your family physician, psychiatrist, or Crisis Services at 834-3131 or Spectrum Cares at 882-4357 (a 24-hour crisis hot-line with counselors that can insure your safety or talk to you about the crisis). If I know that I will be out of town for an extended period of time, I will have another counselor designated to be on-call for me in crisis situations. If you feel that you might potentially utilize these crises options, please let me know during our session so that we can develop a comprehensive crisis plan. Both law and the standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in situations where you are a danger to yourself (or others) or where others have supplied information to me confidentially, you may examine and/or receive a copy of your Clinical Record. This request must be made in writing. Because they are professional records, they can be misinterpreted or upsetting to lay readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. If you would like me to copy your records for you, I will charge a copying fee of 75 cents per page. Please see attached New York Notice Form for a listing of your rights. New York law gives children of any age the right to independently consent to and receive mental health treatment without parental consent if they request it and if it is determined that such services are necessary and requiring parental consent would have a detrimental effect on the course of the child’s treatment. Even where parental consent is given, children over the age of 12 have a right to control access to their treatment records. If you are age 13 or older, I will request an agreement from your parents that they consent to allow me to maintain your confidentiality. If they agree, I will provide them only with general information about our work together unless prohibited by contractI feel that there is a high risk that you will seriously harm yourself, harm another, or are in an abusive situation. In these situations, I will notify them of my concerns about your safety. If they request it, I will provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you (if possible), and will do the best I can to resolve any objections you may have about what I am prepared to discuss with your parents.