Date Format: MM slash DD slash YYYY
Date Format: MM slash DD slash YYYY
Choices Psychotherapy is dedicated to providing you with high quality mental health care. We are in-network providers with most insurance companies and will submit invoices to them for payment on your behalf.
- 1. Clients wishing to use insurance benefits need to provide Choices Psychotherapy with their current insurance information when scheduling the first appointment. We will verify benefits and obtain necessary authorizations.
2. Verification of benefits is not a guarantee of payment and it is the clients’ responsibility to call the customer service number on the back of their insurance card to have a full understanding of what services are covered. It is also the clients’ responsibility to notify Choices Psychotherapy of any insurance changes. Failure to do so, which could result in a claim denial will then be the responsibility of the client to pay.
3. It is your responsibility to know your co-pay, deductible, and co-insurance prior to your initial appointment. Clients are required to pay for all sessions at the time of service, unless coverage through an insurance plan for which we are providers has been verified. Therapy fees are $175.00 for an initial assessment and $175.00 for follow-up sessions. Psychiatry fees are $475.00 for an initial assessment and $350.00 per hour follow-up session and $175.00 per half hour follow up session. We accept check, cash, or credit card. A NSF fee of $40.00 will be collected on all returned checks.
4. CO-PAYMENTS, in the form of check, cash, or credit card are due at the time of service. We cannot waive co-pays, co-insurance or deductibles.
5. If you have a co-insurance and/or deductible to be paid by you, this amount is due when the claim is processed. 6. Choices Psychotherapy requires a credit card on file for all clients with a deductible and/or co-insurance. Your credit card, encrypted and stored securely, will be charged for any unpaid balance after the due date. Clients are encouraged to and always have the opportunity to pay on-line, by mail or in person, prior to their card being charged.
7. Statements will be mailed to clients on a bi-monthly basis. A $10.00 late fee will be assessed on past due accounts and service(s) may be temporarily interrupted until the account is current.
8. If financial difficulties or hardship arise, clients are encouraged to call Choices Psychotherapy’s billing department at 612-212-8244 to make acceptable payment arrangements. These arrangements will be determined on a case-by-case basis.
9. A client may leave therapy at any time, and by signing this document client agrees to pay all outstanding fees associated with their account immediately. Failure to do so will result in additional fees being assessed, including Court filing fees if applicable.
Cancellation/No Show Policies
- CANCELLATION OF SCHEDULED APPOINTMENTS MUST BE DONE 2 BUSINESS DAYS PRIOR TO APPOINTMENT.
- THERAPY: If the 2 business day cancellation requirement is not met, a $75 “Late-Cancel” fee will be assessed. If a client is able to reschedule the missed appointment within the same week, fees will not be assessed. “No-Shows” will result in a $100.00 fee and all future appointments may be cancelled.
If two therapy appointments are missed, either by “Late Cancellation” or “No-Show,” all future appointments may be cancelled. If recurring appointments are cancelled, it is the client’s responsibility to make contact with their therapist, and to present a plan to reestablish services, which initially may be done on a “same-day” appointment basis, per the availability of the therapist and clinical necessity. Termination of services may also be considered by the therapist.
- PSYCHIATRY: If the 2 business day cancellation requirement is not met, a $100.00 “Late-Cancel” fee will e assessed. It may also result in no future appointments being scheduled. “No-Shows” will result in a $200.00 fee and all future appointments being cancelled.
Consideration to be rescheduled for No-Shows will require a patient letter be written to the Psychiatrist, requesting reinstatement of services. A No-Show fee will also be collected.
- All assessed late cancel or no-show fees will be collected AT CHECK-IN prior to next encounter with provider, OR with payment of invoiced monthly statement, WHICHEVER COMES FIRST.
Insurance companies do not pay for missed appointments. Failure to attend scheduled appointments may result in all future appointments being cancelled. Instances of this fee being waived require a providers recommendation due to client extenuating circumstances and administrative approval.
Written Acknowledgement of Billing & Cancellation Policies
- Reminder Notifications For Services & Cancellation Policy
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