Payment and Insurance. Payment for invoices, as well as insurance requirements are due 10 days prior to the event. The District is not a sponsor or participant in the activities related to this facility use agreement. District employees that use or participate do so outside of the course and scope of their employment and are not covered under the District’s Worker Compensation program. See page 4 of this contract for insurance requirements.
Payment and Insurance. It is your responsibility to pay for the services you received at Graceway Psychology Group, LLC. If you opt to use your insurance coverage for services, please be aware ofthe following: • A mental-health related diagnosis will need to be included in each claim. It may become part of your permanent mental-health record. • • Your benefit for psychotherapy might not be the same as your benefit of psychological testing. • With insurance, there is no guarantee of payment, and you are responsible for all fees that your insurance provider does not cover. • Insurance does not cover payment for missed appointments or appointments cancelled with less than 24- hour notice. If you choose to have treatment service be kept private, no diagnosis will be entered in your permanent medical records and your insurance provider would not be informed of your treatment. Payment can be made by cash, credit card, or check payable to Graceway Psychology Group, LLC. There is a $35.00 fee for all returned checks. If your account has not been paid for more than 30 days and arrangements for payment have not been agreed upon, your services will be terminated. Graceway Psychology Group, LLC has the option of pursuing any payment permitted by law.
Payment and Insurance. Payment is expected at each session. Acceptable payments include cash, personal checks, bank debit, major credit, and Health Savings Fund cards. If you choose to use a credit card, a % .04 will be added to total amount charged. We are in-network providers with several insurance companies including: Aetna, Cigna, Highmark, Tricare, Blue Cross/Blue Shield (non-personal choice), and United Health Care. And, as a courtesy we provide electronic submissions of out-of-network insurance plans to expedite any reimbursements that your plan may allow. ▪ NO INSURANCE, SELF PAY RATE $ ▪ INSURANCE COMPANY ▪ MEMBER ID # ▪ INSURANCE IN-NETWORK RATE $ ▪ OUT-OF-NETWORK RATE $ APPOINTMENT AND CANCELLATION POLICY Session time with our clients is very important to us. We require 24-hour notification before an appointment to cancel or reschedule. Please note it is the client’s responsibility, and insurance companies cannot be billed for any late cancellation/missed appointment fees. There will be a $100.00 fee for late cancellations. credit card will be kept on file and charged accordingly. Card # Security Code Exp Date Zip Code Receipts Emailed to or Texted to No receipt, thanks. MEDICATIONS Medication Dosage Frequency Start Date Allergies? Yes / No If yes, describe PLEASE LIST ANY SUBSTANCES YOU CURRENTLY USE, IF ANY; (ALCOHOL, CIGARETTES, VAPES, ETC.) Substance Amount Frequency Age/Date Started Date of Recent Use NOTICE OF HIPAA PRIVACY PRACTICES ***I WAS GIVEN AND READ OR WENT OVER HIPAA LAWS WITH MY THERAPIST Confidentiality & Privacy Policy The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission. Exceptions include: • Suspected child abuse or dependent adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately. • If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim. • If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law to ensure their safety. ACKNOWLEDGEMENT OF PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENT My signature below indicates that I am over the age of 14 and have read, understand and agree to the terms of The Resilience Group by Xxxxx Xxxx Psychotherapist-Client Services Agreement. PR...
Payment and Insurance. All payment for services is due immediately prior to your meeting. In order for us to set realistic treatment goals and priorities, it is important that we both understand what resources you have available to pay for your treatment. We generally discourage any accumulation of debt. If your account has not been paid for more than ninety days and arrangements for payment have not been agreed upon, Xxxxx Mental Health Counseling Services, LLC has the option of using legal means to secure the payment. This may involve hiring a collection agency or going to small claims court which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a client’s treatment is his/her name, the nature of the services provided, and the amount due. If such legal action is necessary, those costs will be included in the claims. If you plan to use health insurance, it will usually provide some coverage for mental health treatment. Many insurance companies require that you obtain authorization from them before you first make an appointment for services. You should always contact your insurance carrier before your first appointment. We will fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however you (not your insurance company) are responsible for ensuring that we receive full payment of our fees. It is very important that you find out exactly what mental health services your insurance company covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have any questions about your 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, we will be willing to call the company on your behalf. Due to rising costs of health care, insurance benefits have become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Manage 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 limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of funct...
Payment and Insurance. Payment is expected at the time of service. We accept cash, check, and all major credits cards. It is IIAT policy not to let outstanding bills exceed $200 without payment. If a credit card chargeback/reverse or returned check fee occurs, you will be responsible for those fees. IIAT does not participate in any insurance provider networks. We will provide you with an invoice for services that contains the information that most insurance companies request. It will be your responsibility to submit your bills for reimbursement. If you request, we will complete forms that are required by your insurance provider once you have signed a release of information authorizing us to provide information about your treatment. Please note that the diagnostic and clinical information that is released will become part of the insurance company's records. Each company has it own procedures for handling and storing your information. We cannot guarantee that they will handle with the appropriate confidentiality once it leaves our office. If you have TRICARE insurance there is an additional form that needs to be reviewed and signed in order for you to seek reimbursement.
