Common use of Insurance Reimbursement Clause in Contracts

Insurance Reimbursement. If you have health insurance, your behavioral health treatments may be covered in whole or in part. The BHCTC will assist you in determining your insurance coverage and will help you fill out any forms needed. Many managed care plans often require an authorization before treatment can begin. You may be required to contact your insurance company to obtain this authorization and/or receive it from your primary care physician. Many managed care plans limit counseling and therapy services to short-term treatment designed to work out specific problems that prevent people from living and working as they normally do. As this is the BHCTC’s model of treatment, this often works out well. Where necessary, we may request more sessions from the managed care plan. In order to do so, we are typically required to complete the insurance company’s forms which may include providing your diagnosis, the reasons you have sought treatment from the BHCTC, the symptoms you are suffering, and how long we believe treatment will or should continue. The information provided will become part of the insurance company’s files. Insurance companies are obligated to keep this information confidential; however, please note that the BHCTC has no control over the handling of this information by the insurance company. If you receive treatment from one of our NJ Licensed Psychologists, your insurance company may request that you authorize the psychologist to disclose certain confidential information in order to obtain insurance coverage benefits for these services. This disclosure can occur only if it is pursuant to a valid authorization and the information is limited to: 1) administrative information (name, age, sex, fees, dates, nature of sessions, etc.); 2) diagnostic information; 3) the status of the patient (voluntary/involuntary; inpatient/outpatient); 4) the reason for continuing psychological services (limited to an assessment of the current level of functioning and the level of distress both rated as mild, moderate, severe or extreme); and 5) a prognosis, limited to the estimated minimal length of treatment. If the Insurance Company has reasonable cause to believe that the psychological treatment in question may not be usual, customary or is unreasonable, it may request an independent review of such treatment by an independent review committee. While a lot can be accomplished in short-term therapy, some people feel they need more services after their insurance benefits end. If this is the case with you, we will discuss what our fees are and the best way for you to arrange payment in order to receive continued treatment. If your insurance company does not allow us to see you after your benefits end, we will be happy to assist you in finding another therapist who will work well with you.

Insurance Reimbursement. In order for us to set realistic treatment goals and priorities, It is I important to evaluate the resources you have available to pay for your treatment. I am a “fee for service” provider and therefore am not on any insurance panel. Therefore, it is very important that you find out exactly what “out 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 health insurancequestions about the coverage, call your behavioral health treatments may plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be covered in whole or in part. The BHCTC will assist happy to help you in determining your insurance coverage and will help understanding the information you fill out any forms needed. Many managed care plans often require an authorization before treatment can begin. You may be required to contact your insurance company to obtain this authorization and/or receive it from your primary care physician. Many managed care plans limit counseling and therapy services to short-term treatment designed to work out specific problems that prevent people from living and working as they normally do. As this is the BHCTC’s model of treatment, this often works out well. Where necessary, we may request more sessions from the managed care plan. In order to do so, we are typically required to complete the insurance company’s forms which may include providing your diagnosis, the reasons you have sought treatment from the BHCTC, the symptoms you are suffering, and how long we believe treatment will or should continue. The information provided will become part of the insurance company’s files. Insurance companies are obligated to keep this information confidential; however, please note that the BHCTC has no control over the handling of this information by the insurance company. If you receive treatment from one of our NJ Licensed Psychologistschoose to submit for reimbursement, I will provide you with an invoice that has the information you well need to complete the forms for your insurance company. Please be aware that most insurance companies require your clinical diagnosis be included on any reimbursement form. Sometimes your insurance company request I submit additional clinical information, such as treatment plans, progress notes or summaries, or copies of the entire record (in rare cases). This information will become xxx of the insurance company files. Although all insurance companies claim to keep such information confidential, I have not control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any records I submit if you request it. It 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. *Children are not typically treated in isolation; therefore parent involvement is often part of the intervention plan. Sessions will be scheduled based on need and may either be conjoint (with the child) or separate in parenting sessions. * This practice includes the use of nurturing touch for young children when appropriate to child’s diagnosis and to promote eye-contact, shared attention and/or reciprocal interaction. Touch provided may include tickling, light and deep pressure touch and is directed by the child’s experience of comfort. Touch provided in the course of treatment is consistent with the goals of promoting in the child physiological regulation, comfort, stress reduction, reciprocal interaction and/or playfulness. *Parents must accompany minors to and from sessions. 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 authorize 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 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 certain confidential 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 have the right to prevent me from providing any information about your 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 obtain defend myself. ● If a patient uses health insurance coverage benefits for these services. This HMO/PPO/EAP/MCO, disclosure can occur only if it is pursuant to a valid authorization and the of confidential information is limited to: 1) administrative information (name, age, sex, fees, dates, nature of sessions, etc.); 2) diagnostic information; 3) the status of the patient (voluntary/involuntary; inpatient/outpatient); 4) the reason for continuing psychological services (limited to an assessment of the current level of functioning and the level of distress both rated as mild, moderate, severe or extreme); and 5) a prognosis, limited to the estimated minimal length of treatment. If the Insurance Company has reasonable cause to believe that the psychological treatment in question may not be usual, customary or is unreasonable, it may request an independent review of such treatment required by an independent review committee. While a lot can be accomplished in short-term therapy, some people feel they need more services after their your health insurance benefits end. If this is the case with you, we will discuss what our fees are and the best way for you to arrange payment carrier in order to receive continued treatmentprocess the 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 your insurance company does not allow us I observe or have knowledge of an incident that reasonably appears to see you after your benefits endbe physical abuse, we will 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 happy may be required to assist you in finding another therapist who will work well with youprovide additional information.

Insurance Reimbursement. If you have a health insuranceinsurance policy, it will usually provide some coverage for mental health treatment. I will facilitate your behavioral health treatments may be covered in whole or in part. The BHCTC will assist receipt of the benefits to which you in determining your are entitled including filling out forms and speaking with insurance coverage and will help you fill out any forms needed. Many managed care plans often require an authorization before treatment can beginrepresentatives. You may will be required to contact held responsible for full payment of our agreed upon fee should your insurance company to obtain this authorization and/or receive deny benefits or should your coverage lapse. Therefore, it from is very important that you find out exactly what mental health benefits your primary care physicianinsurance policy covers. Read your plan carefully and call your service representative if you have questions. Many managed care insurance plans limit counseling and therapy services to require advance authorization before they will provide reimbursement for mental health services. These plans often are oriented toward a short-term model and provide only a certain amount of sessions per 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 designed to work out specific problems that prevent people from living and working as they normally do. As this is or continue our sessions, I will provide them with the BHCTC’s model minimum amount of information needed, usually including a diagnosis, goals for treatment, this often works out welland a brief summary of your current functioning. Where necessaryIt is possible, we may request more sessions from the managed care planbut very rare, that they would require a copy of my clinical record. In order to do so, we are typically required to complete the insurance company’s forms which may include providing your diagnosis, the reasons you have sought treatment from the BHCTC, the symptoms you are suffering, and how long we believe treatment will or should continue. The This information provided will become part of the insurance company’s filescompany files and is likely to be computerized. Insurance All insurance companies are obligated claim to keep this such information confidential; however, please note that the BHCTC 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 handling of information with a national medical information data bank. By signing this Agreement, you agree that I can provide requested information by the to your insurance companycarrier. If you receive treatment from one request it, I will provide you with a copy of our NJ Licensed Psychologists, any report that I am asked to submit. I make it my policy to inform you along the way of where we stand with your insurance company may request that you authorize the psychologist to disclose certain confidential and what kind of information in order to obtain they have requested. Should insurance coverage benefits end for these servicessome reason, we can discuss an out-of-pocket session fee. This disclosure You can occur only if it is pursuant always choose to a valid authorization select this option and have the information is limited to: 1) administrative information (name, age, sex, fees, dates, nature of sessions, etc.); 2) diagnostic information; 3) right to pay for my services yourself to avoid the status complexities of the patient (voluntary/involuntary; inpatient/outpatient); 4) the reason for continuing psychological services (limited to an assessment of the current level of functioning and the level of distress both rated as mild, moderate, severe or extreme); and 5) a prognosis, limited to the estimated minimal length of treatment. If the Insurance Company has reasonable cause to believe that the psychological treatment in question may not be usual, customary or is unreasonable, it may request an independent review of such treatment by an independent review committee. While a lot can be accomplished in short-term therapy, some people feel they need more services after their insurance benefits end. If this is the case with you, we will discuss what our fees are and the best way for you to arrange payment in order to receive continued treatment. If your insurance company does not allow us to see you after your benefits end, we will be happy to assist you in finding another therapist who will work well with youindustry.

Insurance Reimbursement. It is the patient’s responsibility to verify my membership as a provider on his/her insurance plan, to know the expected amount of co-pay and deductible such plan requires to be met, and to obtain a pre-authorization of services before the initial session, if required. Knowing what your policy requires and what mental health services will be covered is of great value to you. You may want to carefully read the section in your insurance coverage booklet that describes mental health services. If you have health insurance, questions about your behavioral health treatments may be covered in whole or in part. The BHCTC will assist you in determining your insurance coverage and will help you fill out any forms needed. Many managed care plans often require an authorization before treatment can begin. You may be required to contact your insurance company to obtain this authorization and/or receive it from your primary care physician. Many managed care plans limit counseling and therapy services to short-term treatment designed to work out specific problems that prevent people from living and working as they normally do. As this is the BHCTC’s model of treatment, this often works out well. Where necessary, we may request more sessions from the managed care plan. In order to do so, we are typically required to complete the insurance company’s forms which may include providing your diagnosis, the reasons you have sought treatment from the BHCTC, the symptoms you are suffering, and how long we believe treatment will or should continue. The information provided will become part of the insurance company’s files. Insurance companies are obligated to keep this information confidential; howevercoverage, please note that the BHCTC has no control over the handling of this information by the insurance companycall your plan administrator. If you have a health insurance policy for which I am a provider, my staff will file your insurance for you and help you receive treatment from the benefits to which you are entitled. You will be asked to pay your portion of the fee at each session. You will be billed for co-pays, deductibles, non-covered services and services deemed not medically necessary (i.e. un-kept appointments, testing, phone consultations, school consultation, conjoint sessions, family without patient sessions) as your claims are adjudicated. Tri-Care Members: You will be given paperwork to file your own claims. Since I am not a Tri-Care provider, I do not recognize assignments or discounts which reduce the patient’s share of the cost. As a Tri-Care patient, you will be expected to pay the full amount of the fee. Verification of insurance benefits does not guarantee payment for services. Payment depends on a number of factors including the beneficiary’s eligibility, benefit plan limitations and the coordination of benefits with other plans. Benefits under Managed Care insurance companies often must be pre-certified and deemed medically necessary by the clinical case manager. If my services are not considered medically necessary, you will be billed for these services (see paragraph one at top of our NJ Licensed Psychologiststhis page) At the time of your initial session, you will be asked to bring your insurance card to verify your enrollment. If you do not present this card at your initial session, your insurance will not be filed and you will be expected to pay the full fee. Your insurance will be filed when our office is given this information. Initial: _____ Date: _______ The purpose for therapy is for treatment only and not for making custody recommendations. As a clinician, it is my role to provide treatment, and not to make recommendations to courts in domestic matters. It would be a dual relationship for me to provide clinical services to a family member and then to conduct a custody evaluation by making recommendations to the Court. That would constitute a breach of professional ethics for mental health counselors. If you are involved in domestic litigation or become a party to a divorce or custody action, you agree that you will not call me to court to testify. Courts appoint professionals who have had no prior contact with a family to conduct custody evaluations and to make recommendations to the Court. It is my policy not to testify in such cases, because experience has shown that the professional relationship is often harmed when counselors testify in divorce and custody cases. By signing this form, consenting to treatment, you agree not to call me as a witness in domestic litigation. X ________ (Initial by client) I do hereby seek and consent to participate in evaluation and /or treatment. I have read the above information and understand the contents. I agree to pay for professional services as they are received. If insurance is filed on my behalf, I agree to be financially responsible for any service provided which my insurance company may request that deem not medically necessary. I authorize Xxxxx XxXxxxxxxx, Ph.D., to release any information requested by my insurance carrier for the purpose of processing claims. I agree not to call you authorize as a witness in domestic litigation. I have received information regarding the psychologist to notice of privacy practices which explains how this office will use and disclose certain confidential my health information in order to obtain insurance coverage benefits for these services. This disclosure can occur only if it is pursuant to a valid authorization and the information is limited to: 1) administrative information (name, age, sex, fees, dates, nature of sessions, etc.); 2) diagnostic information; 3) the status of the patient (voluntary/involuntary; inpatient/outpatient); 4) the reason purposes of my treatment, payment for continuing psychological services (limited to an assessment of the current level of functioning my treatment, and the level of distress both rated as mild, moderate, severe or extreme); and 5) a prognosis, limited to the estimated minimal length of treatment. If the Insurance Company has reasonable cause to believe that the psychological treatment in question may not be usual, customary or is unreasonable, it may request an independent review of such treatment by an independent review committee. While a lot can be accomplished in short-term therapy, some people feel they need more services after their insurance benefits end. If this is the case with you, we will discuss what our fees are and the best way for you to arrange payment in order to receive continued treatment. If your insurance company does not allow us to see you after your benefits end, we will be happy to assist you in finding another therapist who will work well with youhealth care operations.

Insurance Reimbursement. For a Psychologist or Psychological Associate to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insuranceinsurance policy, it will usually provide some coverage for mental health treatment. You must find out exactly what mental health services your behavioral health treatments may be covered insurance policy covers. You should carefully read the section in whole or in part. The BHCTC will assist you in determining your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, if it is necessary to clear up any confusion, we will be willing to call the insurance company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and will help you fill out any forms needed. Many managed care plans PPOs often require an authorization before treatment can beginthey provide reimbursement for mental health services. You may be required to contact your insurance company to obtain this authorization and/or receive it from your primary care physician. Many managed care These plans limit counseling and therapy services are often limited to short-term treatment approaches designed to work out specific problems that prevent people from living and working as they normally dointerfere with a person’s usual level of functioning. As this is the BHCTC’s model of treatment, this often works out well. Where necessary, we It may request be necessary to seek approval for more sessions from the managed care plan. In order to do so, we are typically required to complete the insurance company’s forms which may include providing your diagnosis, the reasons you have sought treatment from the BHCTC, the symptoms you are suffering, and how long we believe treatment will or should continue. The information provided will become part of the insurance company’s files. Insurance companies are obligated to keep this information confidential; however, please note that the BHCTC has no control over the handling of this information by the insurance company. If you receive treatment from one of our NJ Licensed Psychologists, your insurance company may request that you authorize the psychologist to disclose therapy after a certain confidential information in order to obtain insurance coverage benefits for these services. This disclosure can occur only if it is pursuant to a valid authorization and the information is limited to: 1) administrative information (name, age, sex, fees, dates, nature number of sessions, etc.); 2) diagnostic information; 3) the status of the patient (voluntary/involuntary; inpatient/outpatient); 4) the reason for continuing psychological services (limited to an assessment of the current level of functioning and the level of distress both rated as mild, moderate, severe or extreme); and 5) a prognosis, limited to the estimated minimal length of treatment. If the Insurance Company has reasonable cause to believe that the psychological treatment in question may not be usual, customary or is unreasonable, it may request an independent review of such treatment by an independent review committee. While a lot can be accomplished in short-term therapy, some people patients feel that they need more services after their insurance benefits end. Some managed-care plans will not allow Psychologists or Psychological Associates to provide services to you once your benefits end. If this is the case with youcase, we will discuss do our best to find another provider who will help you continue your psychotherapy. You should also be aware that most insurance companies require us to provide them with a clinical diagnosis. Sometimes a Psychologist or Psychological Associate also must provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in some cases). This information 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, we have no control over what our fees 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. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. Psychologists or Psychological Associates are often not immediately available by telephone. Working hours are between 6 AM and 6 PM, so you are not likely to get an answer by phone when in sessions with clients, so email is a preferred method of contact. When unavailable, the best way telephone is answered by a voice mail system that the Psychologist or Psychological Associate monitors frequently. The Psychologist or Psychological Associate will make every effort to return your call within 48 hours of when you call, except for weekends and holidays. If you are difficult to arrange payment reach, please inform me of some times when you will be available. You may prefer to send a T-secure message or T-secure email in your client portal to set or reschedule appointments or share something with me but please be aware that phone, voicemail, and Gmail or other forms of email are not a confidential means of communication, and it would be better to leave a brief message and send a T-Secure email. If you are unable to reach your Psychologist or Psychological Associate and feel that you can’t wait because of safety issues, contact your family physician, call 911, or go to the nearest emergency room and ask for the psychologist or psychiatrist on call. If we are unavailable for any extended period, we will provide you with the name of a colleague to contact, if necessary. In the event, we speak by phone regarding a brief update or conversation about your treatment needs and it is not at a set session time for more than 15 minutes you will be billed for a 30-minute session. The laws and standards of my profession require that a Psychologist or Psychological Associate keep treatment records to plan and describe treatment. Records will be maintained in an Electronic Medical Record data system and in a secure location (locked) to maintain confidentiality. Information will be shared as necessary for the review of treatment plans, assessing the quality of care, and filing third-party reimbursement claims. Contact with other professionals, family members, or individuals requires your written consent or an order from the court to release any information. You are entitled to receive continued treatment. If your insurance company does not allow us to see a copy of the records unless you after your benefits endbelieve that seeing them would be emotionally damaging, in which case we will be happy to assist send them to a mental health professional of your choice. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. We recommend that you review them in finding my presence to discuss the contents. The law mandates reporting any suspected child or vulnerable adult abuse to the proper authorities. In the case of clear and substantial risk, imminent serious harm to the client or another therapist individual disclosure of this information to others without consent is permitted. Patients will be charged an appropriate fee for any time spent preparing information requests. Records reviews and completion of letters confirming attendance, treatment, or assessment summaries will be billed per the rate listed according to the fee schedules that are posted on the website at xxx.xxxxxxxxxxx.xxx for both the Psychologist xxxxx://xxx.xxxxxxxxxxx.xxx/dr-xxxxxx-xxxx-xxxxx/ and Psychological Associate xxxxx://xxx.xxxxxxxxxxx.xxx/psychological-associate/ and will be attached to these forms. Your signing of the informed consent gives full permission for the Psychologist or Psychological Associate to see your child or adolescent for therapeutic services. All parents and legal guardians of the child or adolescent will have full access to records according to the California state statutes and HIPAA regulations unless there is information regarding pregnancy, birth control, abortion, STD, or chemical dependency. These issues are protected and private information for adolescents; their rights to privacy are protected unless they give written consent identifying who they want this information to go to. Parents and guardians otherwise have access to mental health records. Parents and guardians will work well be advised, as is congruent with you.research, that children and adolescents be allowed their privacy to information. Clients and parents or guardians will always be advised that information important to the improvement of relationships will be shared in a therapy session. The only times confidentiality will be superseded are if there is a court order for records, abuse is currently occurring, or if there is a plan for self- harm or for the harm of another person. In cases of shared custody, the Psychologist or Psychological

Insurance Reimbursement. In order for you and Xx. Xxxxxx to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insuranceinsurance policy, it will usually provide some coverage for mental health treatment. With your behavioral health treatments may be covered in whole or in partpermission, Xx. The BHCTC Xxxxxx'x billing service and Xx. Xxxxxx will assist you to the extent possible in determining filing claims and ascertaining information about your insurance coverage, but you are responsible for knowing your coverage and will help you fill out any forms neededfor letting Xx. Many managed care Xxxxxx know if/when your coverage changes. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. Managed Health Care plans such as HMOs and PPOs often require an authorization before advance authorization, without which they may refuse to provide reimbursement for mental health services. These plans are often limited to short-­‐term treatment can begin. You may be required to contact your insurance company to obtain this authorization and/or receive it from your primary care physician. Many managed care plans limit counseling and therapy services to short-term treatment approaches designed to work out specific problems that prevent people from living and working as they normally dointerfere with a person’s usual level of functioning. As this is the BHCTC’s model of treatment, this often works out well. Where necessary, we It may request be necessary to seek approval for more sessions from the managed care plan. In order to do so, we are typically required to complete the insurance company’s forms which may include providing your diagnosis, the reasons you have sought treatment from the BHCTC, the symptoms you are suffering, and how long we believe treatment will or should continue. The information provided will become part of the insurance company’s files. Insurance companies are obligated to keep this information confidential; however, please note that the BHCTC has no control over the handling of this information by the insurance company. If you receive treatment from one of our NJ Licensed Psychologists, your insurance company may request that you authorize the psychologist to disclose therapy after a certain confidential information in order to obtain insurance coverage benefits for these services. This disclosure can occur only if it is pursuant to a valid authorization and the information is limited to: 1) administrative information (name, age, sex, fees, dates, nature number of sessions, etc.); 2) diagnostic information; 3) the status of the patient (voluntary/involuntary; inpatient/outpatient); 4) the reason for continuing psychological services (limited to an assessment of the current level of functioning and the level of distress both rated as mild, moderate, severe or extreme); and 5) a prognosis, limited to the estimated minimal length of treatment. If the Insurance Company has reasonable cause to believe that the psychological treatment in question may not be usual, customary or is unreasonable, it may request an independent review of such treatment by an independent review committee. While a lot can be accomplished in short-term short-­‐term therapy, some people patients feel that they need more services after their insurance benefits end. Some managed-­‐care plans will not allow Xx. Xxxxxx to provide services to you once your benefits end. If this is the case with youcase, we Xx. Xxxxxx will discuss what our fees are and the do her best way for to find another provider who will help you continue your psychotherapy. You should also be aware that most insurance companies require you to arrange payment authorize Xx. Xxxxxx to provide them with a clinical diagnosis. (Diagnoses are technical terms that describe the nature of your problems and whether they are short-­‐term or long-­‐term problems. All diagnoses come from a book entitled the DSM 5. There is a copy in order Xx. Xxxxxx'x office and she will be glad to receive continued treatmentlet you see it to learn more about your diagnosis, if applicable). If your Sometimes Xx. Xxxxxx has 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 does not allow us files and will probably be stored in a computer. Though all insurance companies claim to see keep such information confidential, Xx. Xxxxxx has no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. Xx. Xxxxxx will provide you after with a copy of any report she submits, if you request it. By signing this Agreement, you agree that Xx. Xxxxxx can provide requested information to your benefits end, we will be happy carrier if you plan to assist you in finding another therapist who will work well pay with youinsurance.

Insurance Reimbursement. I am an in-network provider with many insurance providers. If you have health insurance, your behavioral health treatments may be covered in whole or in part. The BHCTC will assist you in determining choose to use your insurance coverage and but your status changes, it is your responsibility to inform me as soon as possible so we can discuss any possible changes to your payment process. If you switch to a company with whom I am not in-network we will help establish the best possible treatment plan for you, which may include referring you fill out any forms neededto another in-network provider. Many managed care plans often require an authorization before treatment can begin. You may be required When you choose to contact allow your insurance company to obtain this authorization and/or receive it from contribute payment to your primary care physiciantreatment you do allow them access to your clinical records. Many managed care plans limit counseling and therapy services to short-term treatment designed to work out specific problems that prevent people from living and working as they normally do. As this is the BHCTC’s model of treatment, this often works out well. Where necessary, we may request more sessions from the managed care plan. In order to do so, we are typically I will be required to complete the insurance company’s forms which may include providing your diagnosis, the reasons provide you have sought treatment from the BHCTC, the symptoms you are suffering, with a diagnosis and how long we believe treatment will or should continue. The information provided will become part of the insurance company’s files. Insurance companies are obligated to keep this information confidential; however, please note share that the BHCTC has no control over the handling of this information by diagnosis with the insurance company. If you receive treatment from one of our NJ Licensed Psychologists, your I will also be required to follow a treat- ment plan that relates to that diagnosis. Your insurance company may choose to deny or modify your treatment, based on their medical necessity criteria. Please be advised that should I be requested to write a letter on any court related matter, I will NOT be stipulating in writing or in person as to an opinion. As your therapist, I may only provide observations and feedback. At no time will I make a recommendation in regards to custody or any other court related matter. If a court order is served and is requesting that I be present in person and/or there is a request for records, I will request your consent before turning over confidential information. I will discuss with you exactly what has been requested by court and there is no guarantee that you authorize the psychologist informa- tion will be kept confidential. This information includes mental health history, current status and inclusive records and may not be in your best interest. The therapist-client relationship does not render me as your advocate. I will withhold any opportunity to engage in a dual relationship in this way. Fees: Should I be ordered by court to write a letter to the court, the time shall be billed at $135.00 per hour. Should I be court ordered to appear in court, the fee stipulation is as follows: • $500 per day plus $20.00 per hour for travel to and from the court. • $50 per hour for preparation I will not be on-call at any time. Should a case be trailed, I will be paid in full for each day as well as an additional $500.00per day as it hinders my ability to be available to other clients. All court fees must be received by cashier’s check 14 days prior to the court date. Should the court calendar the hearing for another date, I must be re-issued a court order with the new court hearing date. Should I be on vacation, the party initiating the court order must take reasonable steps to avoid imposing undue burden or expense on a person subject to the subpoena. There are times when I consult with other licensed mental health professionals about my cases. During these discussions, I make sure to disclose certain confidential as little information as possible in order to obtain insurance coverage benefits protect your confidentiality. If I feel there is an instance when consultation may require more in- formation and may be helpful for these servicesour work together, I will talk with you beforehand about how to proceed. This disclosure can occur only if At times it is pursuant helpful to a valid authorization and the information is limited to: 1) administrative information (name, age, sex, fees, dates, nature of sessions, etc.); 2) diagnostic information; 3) the status of the patient (voluntary/involuntary; inpatient/outpatient); 4) the reason for continuing psychological services (limited to an assessment of the current level of functioning and the level of distress both rated as mild, moderate, severe or extreme); and 5) a prognosis, limited to the estimated minimal length of treatment. If the Insurance Company has reasonable cause to believe that the psychological treatment involve important people in question may not be usual, customary or is unreasonable, it may request an independent review of such treatment by an independent review committee. While a lot can be accomplished your life in short-term therapy, some people feel they need more services after their insurance benefits endour work together. If this is the case with yousome- thing that we both feel may be helpful, we will discuss how much information you may be com- fortable disclosing and in what our fees way. I will never speak with any of your family members about your treatment, or even confirm whether or not you are and the best way for you to arrange payment in order to receive continued treatmentmy client, without first having your writ- ten consent. If One exception may be if I am concerned about your insurance company does not allow us to see you after your benefits end, we will be happy to assist you in finding another therapist who will work well with yousafety.

Insurance Reimbursement. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources are available to pay for your treatment. If you have a health insuranceinsurance policy, it will usually provide some coverage for mental health treatment. Studio For Change will provide you with whatever assistance your behavioral health treatments therapist can in facilitating your receipt of the benefits to which you are entitled including filling out forms as appropriate. However, you and not your insurance company are responsible for full payment of the fee that we have agreed to. All of our insurance billing is out-serviced through a second party insurance xxxxxx and invoices for claims not paid by insurance may be covered sent directly to clients from our Studio For Change billing office. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in whole or in partyour insurance coverage booklet that describes mental health services. The BHCTC If you have questions, you should call your plan administrator and inquire. Studio For Change will provide you with whatever information your therapist can based on our experience and will be happy to try to assist you in determining deciphering the information you receive from your carrier. If necessary to resolve confusion, your therapist is willing to call the carrier on your behalf. The escalation of the cost of health care has resulted in an increasing level of complexity about insurance benefits, which sometimes makes it difficult to determine exactly how much mental health coverage is available. “Managed Health Care Plans” such as HMOs and will help you fill out any forms needed. Many managed care plans PPOs often require an advance authorization before treatment can beginthey will provide reimbursement for mental health services. You may be required to contact your insurance company to obtain this authorization and/or receive it from your primary care physician. Many managed care These plans limit counseling and therapy services to are often oriented toward a short-term treatment approach designed to work out resolve specific problems that prevent people from living and working as they normally doare interfering with one’s usual level of functioning. As this is the BHCTC’s model It may be necessary to seek additional approval after a certain number of treatment, this often works out well. Where necessary, we may request more sessions from the managed care plansessions. In order to do soour experience, we are typically required to complete the insurance company’s forms which may include providing your diagnosis, the reasons you have sought treatment from the BHCTC, the symptoms you are suffering, and how long we believe treatment will or should continue. The information provided will become part of the insurance company’s files. Insurance companies are obligated to keep this information confidential; however, please note that the BHCTC has no control over the handling of this information by the insurance company. If you receive treatment from one of our NJ Licensed Psychologists, your insurance company may request that you authorize the psychologist to disclose certain confidential information in order to obtain insurance coverage benefits for these services. This disclosure can occur only if it is pursuant to a valid authorization and the information is limited to: 1) administrative information (name, age, sex, fees, dates, nature of sessions, etc.); 2) diagnostic information; 3) the status of the patient (voluntary/involuntary; inpatient/outpatient); 4) the reason for continuing psychological services (limited to an assessment of the current level of functioning and the level of distress both rated as mild, moderate, severe or extreme); and 5) a prognosis, limited to the estimated minimal length of treatment. If the Insurance Company has reasonable cause to believe that the psychological treatment in question may not be usual, customary or is unreasonable, it may request an independent review of such treatment by an independent review committee. While while quite a lot can be accomplished in short-term therapy, some people many clients feel they need that more services are necessary after their insurance benefits endexpire. You should also be aware that most insurance agreements require you to authorize your therapist to provide a clinical diagnosis and sometimes additional clinical information such as a treatment plan or summary or in rare cases a copy of the entire record. This information will become part of the insurance company files, and, in all probability, some of it will be computerized. All insurance companies claim to keep such information confidential, but once it is in their hands, your therapist will have no control over what they do with it. In some cases they may share the information with a national medical information data bank. If this is you request it, your therapist can provide you with a copy of any report submitted. Once the case with youStudio For Change has all of the information about your insurance company, we your therapist will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for our fees are services yourself and avoid the best way for you to arrange payment in order to receive continued treatment. If your insurance company does not allow us to see you after your benefits end, we will be happy to assist you in finding another therapist who will work well with youcomplexities described above.

Insurance Reimbursement. It is the patient’s responsibility to verify my membership as a provider on his/her insurance plan, to know the expected amount of co-pay and deductible such plan requires to be met, and to obtain a pre-authorization of services before the initial session, if required. Knowing what your policy requires and what mental health services are covered will be of great value to you. You may want to carefully read the section in your insurance coverage booklet that describes mental health services. If you have health insurance, questions about your behavioral health treatments may be covered in whole or in part. The BHCTC will assist you in determining your insurance coverage and will help you fill out any forms needed. Many managed care plans often require an authorization before treatment can begin. You may be required to contact your insurance company to obtain this authorization and/or receive it from your primary care physician. Many managed care plans limit counseling and therapy services to short-term treatment designed to work out specific problems that prevent people from living and working as they normally do. As this is the BHCTC’s model of treatment, this often works out well. Where necessary, we may request more sessions from the managed care plan. In order to do so, we are typically required to complete the insurance company’s forms which may include providing your diagnosis, the reasons you have sought treatment from the BHCTC, the symptoms you are suffering, and how long we believe treatment will or should continue. The information provided will become part of the insurance company’s files. Insurance companies are obligated to keep this information confidential; howevercoverage, please note that the BHCTC has no control over the handling of this information by the insurance companycall your plan administrator. If you have a health insurance policy for which I am a provider, my staff will file your insurance for you and help you receive treatment from the benefits to which you are entitled. You will be asked to pay your portion of the fee at each session. You will be billed for co-pays, deductibles, non-covered services and services deemed not medically necessary (i.e. un-kept appointments, testing, phone consultations, school consultation, conjoint sessions, family without patient sessions) as your claims are adjudicated. Tri-Care Members: You will be given paperwork to file your own claims. Since I am not a Tri-Care provider, I do not recognize assignments or discounts which reduce the patient’s share of the cost. As a Tri-Care patient, you will be expected to pay the full amount of the fee. Verification of insurance benefits does not guarantee payment for services. Payment depends on a number of factors including the beneficiary’s eligibility, benefit plan limitations and the coordination of benefits with other plans. Benefits under Managed Care insurance companies often must be pre-certified and deemed medically necessary by the clinical case manager. If my services are not considered medically necessary, you will be billed for these services (see paragraph one at top of our NJ Licensed Psychologiststhis page) At the time of your initial session, you will be asked to bring your insurance card to verify your enrollment. If you do not present this card at your initial session, your insurance will not be filed and you will be expected to pay the full fee. Your insurance will be filed when our office is given this information. The purpose for therapy is for treatment only and not for making custody recommendations. As a clinician, it is my role to provide treatment, and not to make recommendations to courts in domestic matters. It would be a dual relationship for me to provide clinical services to a family member and then to conduct a custody evaluation by making recommendations to the Court. That would constitute a breach of professional ethics for mental health counselors. If you are involved in domestic litigation or become a party to a divorce or custody action, you agree that you will not call me to court to testify. Courts appoint professionals who have had no prior contact with a family to conduct custody evaluations and to make recommendations to the Court. It is my policy not to testify in such cases, because experience has shown that the professional relationship is often harmed when counselors testify in divorce and custody cases. By signing this form, consenting to treatment, you agree not to call me as a witness in domestic litigation. X ________ (initial by client) I do hereby seek and consent to participate in evaluation and /or treatment. I have read the above information and understand the contents. I agree to pay for professional services as they are received. If insurance is filed on my behalf, I agree to be financially responsible for any service provided which my insurance company may request that deem not medically necessary. I authorize Xxx Xxxxxxxx, X.Xx.xx release any information requested by my insurance carrier for the purpose of processing claims. I agree not to call you authorize as a witness in domestic litigation. I have received information regarding the psychologist to notice of privacy practices which explains how this office will use and disclose certain confidential my health information in order to obtain insurance coverage benefits for these services. This disclosure can occur only if it is pursuant to a valid authorization and the information is limited to: 1) administrative information (name, age, sex, fees, dates, nature of sessions, etc.); 2) diagnostic information; 3) the status of the patient (voluntary/involuntary; inpatient/outpatient); 4) the reason purposes of my treatment, payment for continuing psychological services (limited to an assessment of the current level of functioning my treatment, and the level of distress both rated as mild, moderate, severe or extreme); and 5) a prognosis, limited to the estimated minimal length of treatment. If the Insurance Company has reasonable cause to believe that the psychological treatment in question may not be usual, customary or is unreasonable, it may request an independent review of such treatment by an independent review committee. While a lot can be accomplished in short-term therapy, some people feel they need more services after their insurance benefits end. If this is the case with you, we will discuss what our fees are and the best way for you to arrange payment in order to receive continued treatment. If your insurance company does not allow us to see you after your benefits end, we will be happy to assist you in finding another therapist who will work well with youhealth care operations.