Common use of Financial Responsibilities Clause in Contracts

Financial Responsibilities. Unless other agreements are made with you or your health insurance provider, all clients are expected to make full payment at the time of service. Copays should be paid to the Green House Group, P.A. and remitted directly through your therapist at the time of service, preferably by cash or check although we do accept most major credit cards. Credit card payments of $300 or greater will incur a 2% service fee at the time of transaction. You have the option to leave a credit or debit card on file to facilitate regular payments at the time of services. Many clients elect to use their health insurance which typically provides coverage for mental health services. While we may be able to negotiate professional fees to a limited extent, unless you waive your right to use health insurance for services, we must honor whatever contractual obligations exist with that organization. Should you wish to avoid certain complexities involved in using your insurance for clinical services, you and your therapist can discuss and agree to other fee arrangements. Under this condition it is important to know that you, not your insurance company, are responsible for full payment of that fee. Your health insurance will only reimburse for “medically necessary” services. We are often requested to provide other forms of professional services, such as reports, letters, consultations with other professionals (with your authorization) and extended telephone discussions (greater than 10 minutes). These types of services will be billed to the client on a prorated basis at the same hourly rate for psychotherapy ($140/ hour). If you are unable to attend or cancel a scheduled appointment your are expected to provide the therapist with at least a 24-hour (business hours) notification, including Fridays for Monday appointments; and will be expected to pay for that session in full unless other arrangements are made with your therapist. This charge is not reimbursable by insurance and due at the time of your next appointment. Please speak with your clinician as to how such charges will be implemented. Please make every effort to discuss any financial concerns with your therapist and/ or our billing department (Extension *21). We, in turn, will make every effort to address and resolve these issues. Unless other arrangements are made, overdue accounts (90+ days) will be considered excessive and our billing department will contact you to develop a payment plan. Accounts greater than 120+ days which have not responded to our request for payment arrangements may be referred to a local collection agency. Should that circumstance occur, we are required to provide the agency with limited information: Your name/ contact data, the nature of services provided and amount due. Using Medical Insurance If you plan to use your health insurance for clinical services it is important that you contact your plan to determine if there are prior authorization requirements and/ or limits of coverage for clinical services. Any changes to your health care plan may require a new authorization which you, the client, are responsible for obtaining prior to your next session. Once you have obtained this information you should discuss with your clinician what types and length of treatment are realistic to expect within the limits of coverage available, and/ or what will happen should those insurance benefits end prior to reaching your treatment goals. Please remember that you always have the right to pay for services yourself and avoid these complexities. Please be aware that in order to reimburse for clinical services, insurance companies require your authorization such that your therapist can provide a clinical diagnosis, and sometimes additional information such as a treatment plan or summary; or in rare cases, a copy of the entire record. Your therapist will make every effort to release only the minimum information that is necessary for the purpose requested. This information will become part of the insurance company’s file; once in their possession your therapist has no control over how that information is managed or protected. Client Rights, Records, Practices, and HIPAA Consistent with state law, the Mental Health Bill of Rights is posted in the waiting room for your review. Please direct any related questions to your therapist. Federal law (HIPAA) and the standards of our profession require that your therapist maintain Protected Health Information (PHI) about you in your Clinical Record. This record contains information regarding your reasons for seeking treatment and the ways this problem impacts your life, diagnosis, treatment goals/ progress, medical, social and treatment history, including past treatment records received from other providers. Additionally, this record may contain a record of professional consultations, your billing records and reports that may have been sent to anyone with your authorization. HIPAA also addresses the use of Psychotherapy Notes, those which are designated to assist the clinician in providing you with quality treatment. These notes may contain contents of discussions with your therapist, some of which may include sensitive information. While insurance companies can request and receive a copy of the Clinical Record, they cannot receive these Psychotherapy Notes without your written consent. You may examine and/ or receive a copy of your record if you make that request in writing. Because these are professional records and are subject to misinterpretation or may be upsetting to untrained readers, we recommend that you initially review them with your therapist, or have them forwarded to another mental health professional with whom you can discuss their contents. You may also revoke this agreement in writing at any time. That revocation will be binding on your therapist and the Green House Group unless your therapist has already taken action in reliance on it; if there are obligations imposed on the therapist by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations incurred. We must obtain your signed authorization before we can release your PHI for any use and disclosure not described above or in the attached HIPAA Privacy Notice. You have the right to restrict disclosures of your PHI at Green house Group to a health plan if you pay out-of-pocket for services. Your therapist will make every effort to provide quality and effective psychological services. If you are dissatisfied with your treatment it is strongly encouraged that you first contact your therapist directly to discuss and hopefully resolve these concerns together. Should you decide to pursue such concerns further and initiate a professional ethics complaint, you should contact either the New Hampshire Board of Mental Health Practice (BMHP) or the New Hampshire Board of Psychologists, as appropriate to the clinician’s licensure; both are located in Concord, New Hampshire. You should also be aware that the presence of a mental health diagnosis and/ or sensitive clinical information within the Clinical Record could potentially impact services you might seek to obtain in the future. For example, applications for life insurance, military service, national security clearance may all be affected. Privacy Practices and Confidentiality The relationship and communications between a licensed mental health professional and client are privileged and confidential in the state of New Hampshire and in accordance with HIPAA regulations. However, state law and the ethics of our profession indicate there are certain exceptions to such privileged confidentiality. Under specific conditions, listed below, the mental health professional cannot be held legally liable for violating the privacy of confidential therapist-client communications. In each instance, every effort will be made to fully discuss these circumstances with the client before taking action.

Financial Responsibilities. Unless other agreements are made with you or your health insurance providerIn consideration of all services and supplies provided by Saint Clair Allergy & Asthma Center, all clients are expected I completely understand and fully agree that I have full responsibility to make pay Saint Clair Allergy & Asthma Center. I hereby guarantee full payment for all charges. If my account is referred to a collection agency or an attorney, I guarantee payment for all collection fees and costs. I understand that the responsibility for payment may not be deferred for any reason. Saint Clair Allergy & Asthma Center may bill my insurance (s), but I and my estate remain fully responsible for full payment. I fully understand and agree to be financially responsible for full payment if any insurance determines services were not referred, authorized, or are non-covered according to my benefits. Saint Clair Allergy & Asthma Center does not deny services to any patients based on their insurance company’s requirements or determinations. • SCAAC accepts cash, personal checks, Visa, MasterCard and Discover. There is a $50.00 processing fee for all non-sufficient check funds. • SCAAC billing structure is compliant with current year CPT. After hour or weekend servicing may be subject to additional charges. • Deductible and/or coinsurance as per your agreement with the insurance company will need to be paid upon request or at the time of service. Unfortunately, some elective procedures cannot be scheduled until this amount is paid. • We do participate with numerous insurance companies, meaning we have a contract with them. Copayments and/or non-covered services are required to be paid in full at the time of service. Copays should be paid to the Green House Group, P.A. and remitted directly through your therapist are due at the time of service, preferably by cash service or check although your appointment will be rescheduled. Our contract with the insurance companies states that patient balances (deductibles/coinsurance) cannot be waived. • There are some insurance companies we do accept most major credit cardsnot participate with under contract. Credit card payments of $300 or greater will incur a 2% service fee You are required to pay all visits in full at the time of transactionthe visit. We will submit a claim to your insurance carrier on your behalf. Any payment from the insurance company will usually be sent directly to you. You have will be responsible for following up with your insurance company regarding any potential reimbursement for the option services rendered. You will be asked to leave a credit or debit card on file pay our charges in full prior to facilitate regular payments services being schedules/rendered. • Payment for services is due in full at the time of servicesservice if there is no medical insurance plan available. Many clients elect to use their health insurance which typically provides coverage for mental health services. While we may be able to negotiate professional fees to a limited extent, unless you waive your right to use health insurance for services, we must honor whatever contractual obligations exist with that organization. Should you wish to avoid certain complexities involved in using your insurance for clinical services, you and your therapist can discuss and agree to other fee arrangements. Under this condition it Payment is important to know that you, not your insurance company, are responsible for full payment of that fee. Your health insurance will only reimburse for “medically necessary” services. We are often requested to provide other forms of professional services, such as reports, letters, consultations with other professionals (with your authorization) and extended telephone discussions (greater than 10 minutes). These types of services will be billed required prior to the client on a prorated basis at the same hourly rate for psychotherapy ($140/ hour)procedure being scheduled. If you are unable to attend or cancel a scheduled appointment your are expected to provide the therapist Please inquire with our office staff regarding payment options. • I understand that Saint Clair Allergy and Asthma Center, PLLC requires at least a 24-hour (business hours) notification, including Fridays for Monday notice to cancel scheduled appointments; and . I understand that I will be expected charged $50 per cancellation or missed/no-show appointment in which I did not notified of Saint Clair Allergy and Asthma Center, PLLC within 24 hours prior to pay my appointment. • I understand that Saint Clair Allergy and Asthma Center, PLLC reserves the right to revoke my appointment privileges and dismiss me from the practice should I acquire 3 missed appointments without a 24-hour notice. • If the insurance plan requires you to obtain a referral from your Primary Care Physician (PCP), you are responsible for that session in full unless other arrangements are made obtaining the referral and presenting it at your visit. If you do not have the referral, the appointment will need to be rescheduled. This is a requirement of your insurance company. As a reminder; your PCP may require at least five (5) days to prepare the referral. Check with your therapistdoctor’s office regarding their specific policy. This charge is • I understand that if I do not reimbursable by present accurate, current and complete billing insurance and due information at the time of your next appointmentservices, I agree to be responsible for any amounts relating to the full payment of any amount not covered by insurance. Please speak with your clinician as to how such charges will be implementedI relieve Saint Clair Allergy & Asthma Center any responsibility in the event correct information was not provided at the time of service. Please make every effort to discuss any financial concerns with your therapist and/ or our billing department A copy of my insurance card (Extension *21). We, in turn, will make every effort to address and resolve these issues. Unless other arrangements are made, overdue accounts (90+ dayss) will be considered excessive and our billing department will contact you maintained to develop verify what was presented to Saint Clair Allergy & Asthma Center. I am aware that a payment plan. Accounts greater than 120+ days which have not responded to our request for payment arrangements may be referred to a local collection agency. Should that circumstance occur, we are non-expired photo identification is required to be on file at Saint Clair Allergy & Asthma Center as required by the Federal Trade Commission to provide proof of identity for claim submission and medical operations. It is impossible for any medical provider to know the agency with limited information: Your name/ contact datainsurance benefits of every patient. Benefits vary based on the wide variety of policies sold to employers and patients. It is your responsibility to know your medical benefits. We will assist you if necessary; however, the nature ultimate responsibility of services provided and amount due. Using Medical Insurance If you plan to use knowing your health insurance for clinical services it is important that you contact your plan to determine if there are prior authorization requirements and/ or limits of coverage for clinical services. Any changes to your health care plan may require a new authorization which benefits rests with you, the client, are responsible for obtaining prior to your next session. Once you have obtained this information you should discuss with your clinician what types and length of treatment are realistic to expect within the limits of coverage available, and/ or what will happen should those insurance benefits end prior to reaching your treatment goals. Please remember that you always have the right to pay for services yourself and avoid these complexities. Please be aware that in order to reimburse for clinical services, insurance companies require your authorization such that your therapist can provide a clinical diagnosis, and sometimes additional information such as a treatment plan or summary; or in rare cases, a copy of the entire record. Your therapist will make every effort to release only the minimum information that is necessary for the purpose requested. This information will become part of the insurance company’s file; once in their possession your therapist has no control over how that information is managed or protected. Client Rights, Records, Practices, and HIPAA Consistent with state law, the Mental Health Bill of Rights is posted in the waiting room for your review. Please direct any related questions to your therapist. Federal law (HIPAA) and the standards of our profession require that your therapist maintain Protected Health Information (PHI) about you in your Clinical Record. This record contains information regarding your reasons for seeking treatment and the ways this problem impacts your life, diagnosis, treatment goals/ progress, medical, social and treatment history, including past treatment records received from other providers. Additionally, this record may contain a record of professional consultations, your billing records and reports that may have been sent to anyone with your authorization. HIPAA also addresses the use of Psychotherapy Notes, those which are designated to assist the clinician in providing you with quality treatment. These notes may contain contents of discussions with your therapist, some of which may include sensitive information. While insurance companies can request and receive a copy of the Clinical Record, they cannot receive these Psychotherapy Notes without your written consent. You may examine and/ or receive a copy of your record if you make that request in writing. Because these are professional records and are subject to misinterpretation or may be upsetting to untrained readers, we recommend that you initially review them with your therapist, or have them forwarded to another mental health professional with whom you can discuss their contents. You may also revoke this agreement in writing at any time. That revocation will be binding on your therapist and the Green House Group unless your therapist has already taken action in reliance on it; if there are obligations imposed on the therapist by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations incurred. We must obtain your signed authorization before we can release your PHI for any use and disclosure not described above or in the attached HIPAA Privacy Notice. You have the right to restrict disclosures of your PHI at Green house Group to a health plan if you pay out-of-pocket for services. Your therapist will make every effort to provide quality and effective psychological services. If you are dissatisfied with your treatment it is strongly encouraged that you first contact your therapist directly to discuss and hopefully resolve these concerns together. Should you decide to pursue such concerns further and initiate a professional ethics complaint, you should contact either the New Hampshire Board of Mental Health Practice (BMHP) or the New Hampshire Board of Psychologists, as appropriate to the clinician’s licensure; both are located in Concord, New Hampshire. You should also be aware that the presence of a mental health diagnosis and/ or sensitive clinical information within the Clinical Record could potentially impact services you might seek to obtain in the future. For example, applications for life insurance, military service, national security clearance may all be affected. Privacy Practices and Confidentiality The relationship and communications between a licensed mental health professional and client are privileged and confidential in the state of New Hampshire and in accordance with HIPAA regulations. However, state law and the ethics of our profession indicate there are certain exceptions to such privileged confidentiality. Under specific conditions, listed below, the mental health professional cannot be held legally liable for violating the privacy of confidential therapist-client communications. In each instance, every effort will be made to fully discuss these circumstances with the client before taking action.