Common use of Private Billing Clause in Contracts

Private Billing. In the event you agree to pay STILLPOINT COUNSELING ASSOCIATES privately for treatment, you will be billed based on our standard rates for services and timely payments must be made in accordance to the rates set forth in Exhibit D. You should also be aware that most insurance companies require you to authorize STILLPOINT COUNSELING ASSOCIATES 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 in nature. All diagnoses come from the diagnostic manual entitled the DSM-V). Sometimes, we have to provide additional clinical information such as treatment plans or summaries, or copies of the patients entire clinical record (this is rare). This information will become part of the insurance company files and will probably be stored in their computer system. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is requested and received. We will provide you a copy of any report or summary we submit, if you requested in writing. By signing this agreement, you agree that STILLPOINT COUNSELING ASSOCIATES can provide the requested information to you carrier if you plan to use insurance funding to pay for treatment. In addition, if you plan to use your insurance, authorization from the insurance company may be required before they will cover therapy fees. If you did not obtain authorization and it is required, you may be responsible for full payment of the fee. Many policies leave a percentage of the fee (which is called co-insurance) or a flat dollar amount (referred to as co-payment) to be covered by the patient. Either amount is to be billed or payed to STILLPOINT COUNSELING ASSOCIATES by the due date listed on your invoices. In addition, some insurance companies also have a deductible, which is an out-of-pocket amount that must be paid by the patient before the insurance companies are willing to begin paying any amount for services. This will typically mean that you will be responsible to pay for initial sessions until your deductible has been met. It is important to note, that many deductible amounts may also need to be met at the start of each calendar year, meaning that new deductibles start January 1st of each new year. Once we have all of the information about your insurance coverage, we will discuss what we can reasonably expect to accomplish with the benefits that are available and what will happen if coverage ends before you feel ready to end your sessions. It is important to remember that you always have the right to pay for services yourself to avoid problems described above, unless prohibited by a provider contract. If we are not a participating provider for your insurance plan, we can supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement upon request. Please note that not all insurance companies reimburse for out-of-network providers. If you prefer to use a participating provider, you can refer to your insurance customer service coordinator and they can refer you to in-network providers. PROFESSIONAL RECORDS We are required by law to keep appropriate records of the psychological services we provide. Your records are maintained in a secure location in each STILLPOINT COUNSELING ASSOCIATES office. We keep brief records noting that you were present, your reasons for seeking therapy services, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social and treatment history, records we receive from other providers, copies of records we sent to others, and your billing records.

Private Billing. In the event you agree to pay STILLPOINT COUNSELING ASSOCIATES privately for treatment, you will be billed based on our standard rates for services and timely payments must be made in accordance to the rates set forth on the Good Faith Estimate form in Exhibit D. You should also be aware that most insurance companies require you to authorize STILLPOINT COUNSELING ASSOCIATES 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 in nature. All diagnoses come from the diagnostic manual entitled the DSM-V). Sometimes, we have to provide additional clinical information such as treatment plans or summaries, or copies of the patients entire clinical record (this is rare). This information will become part of the insurance company files and will probably be stored in their computer system. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is requested and received. We will provide you a copy of any report or summary we submit, if you requested in writing. By signing this agreement, you agree that STILLPOINT COUNSELING ASSOCIATES can provide the requested information to you carrier if you plan to use insurance funding to pay for treatment. In addition, if you plan to use your insurance, authorization from the insurance company may be required before they will cover therapy fees. If you did not obtain authorization and it is required, you may be responsible for full payment of the fee. Many policies leave a percentage of the fee (which is called co-insurance) or a flat dollar amount (referred to as co-payment) to be covered by the patient. Either amount is to be billed or payed to STILLPOINT COUNSELING ASSOCIATES by the due date listed on your invoices. In addition, some insurance companies also have a deductible, which is an out-of-pocket amount that must be paid by the patient before the insurance companies are willing to begin paying any amount for services. This will typically mean that you will be responsible to pay for initial sessions until your deductible has been met. It is important to note, that many deductible amounts may also need to be met at the start of each calendar year, meaning that new deductibles start January 1st of each new year. Once we have all of the information about your insurance coverage, we will discuss what we can reasonably expect to accomplish with the benefits that are available and what will happen if coverage ends before you feel ready to end your sessions. It is important to remember that you always have the right to pay for services yourself to avoid problems described above, unless prohibited by a provider contract. If we are not a participating provider for your insurance plan, we can supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement upon request. Please note that not all insurance companies reimburse for out-of-network providers. If you prefer to use a participating provider, you can refer to your insurance customer service coordinator and they can refer you to in-network providers. PROFESSIONAL RECORDS We are required by law to keep appropriate records of the psychological services we provide. Your records are maintained in a secure location in each STILLPOINT COUNSELING ASSOCIATES office. We keep brief records noting that you were present, your reasons for seeking therapy services, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social and treatment history, records we receive from other providers, copies of records we sent to others, and your billing records.