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. It is also important to remember that you always have the right to pay for your treatment yourself to avoid any insurance issues discussed above.

Insurance Reimbursement. This section applies only if you chose to use your health insurance. In order for us 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 insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are ultimately responsible for full payment of my fees. It is very important that you find out exactly what mental health services are covered by your specific insurance policy. You are always responsible fort all charges for services that are not paid by your insurance plan. If you should change insurance plans, if the terms of your existing insurance plan should change, or if you lose your insurance, you must notify me as soon as possible so that we will have the best opportunity to collect the benefits which are available to you. You should carefully read the section in your behavioral insurance coverage booklet that describes mental health treatments may services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be covered happy to help you in whole understanding the information you receive from your insurance company. If it is necessary to clear confusion, with your permission, I or in partmy staff will call the company on your behalf. The BHCTC 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 authorization before they provide reimbursement for mental health services. These plans sometimes place very arbitrary limits on the kinds of problems and the approaches they cover. Most insurance plans do not provide coverage for the full range of services psychotherapists can provide to help people. While much can be accomplished within the limits imposed by most health insurance plans and managed care organizations, some people feel that they need or would like services beyond the coverage provided by their insurance. If this is the case, we can discuss these issues and related costs as circumstances warrant. If necessary, I will do my best to assist you in determining your insurance coverage finding more affordable, alternative sources for services and will help you fill out any forms needed. Many managed care plans often require an authorization before treatment can begintreatment. You may should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to contact provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of 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 planentire clinical record. In order such situations, I will make every effort to do so, we are typically required to complete release only the insurance company’s forms which may include providing your diagnosis, minimum information about you that is necessary for the reasons you have sought treatment from the BHCTC, the symptoms you are suffering, and how long we believe treatment will or should continuepurpose requested. The This information provided will become part of the insurance company’s filescompany files and will probably be stored in a computer. Insurance Though all insurance companies are obligated claim to keep this such information confidential; however, please note that the BHCTC has I have no control over what they do with it once it is in their hands. In some cases, they may share the handling information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information by the insurance company. If you receive treatment from one of our NJ Licensed Psychologists, to your insurance company may request that you authorize the psychologist to disclose certain confidential information in order to obtain insurance coverage benefits for these servicescarrier. This disclosure can occur only if it is pursuant to a valid authorization and Once we have all of 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 about your insurance benefits end. If this is the case with youcoverage, we will discuss what our fees we can expect to accomplish with the benefits that are available and the best way for what will happen if they run out before you feel ready to arrange payment in order to receive continued treatment. If end 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 yousessions. It is also important to remember that you always have the right to pay for your treatment my services yourself to avoid any insurance issues discussed the problems described above.. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA PRIVACY NOTICE DESCRIBED ABOVE. Patient’s Name Patient’s Signature (or Parent/ Legal Guardian)

Insurance Reimbursement. If Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much, if any, mental health coverage is available. In order to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. It is very important that you find out exactly what mental health insurance, your behavioral health treatments may be covered in whole or in part. The BHCTC will assist you in determining services your insurance coverage and will help you fill out any forms neededpolicy covers as soon as possible. Many managed care plans often require an authorization before treatment can begin. You may be required It is your responsibility to contact your insurance company to obtain verify your coverage and benefits for mental health treatment. If you have a health insurance policy, it may or may not provide some coverage for mental health treatment. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. This office will provide you with assistance, if possible, (for example providing required treatment plans) to help you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of this authorization and/or receive it from office’s fees. Once this office has all of the information about your primary care physicianinsurance coverage, your counselor will discuss with you what you can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. Many managed care You should also be aware that your contract with your health insurance company requires that this office provide them with information relevant to the services that are provided to you. This office is required to provide a clinical diagnosis to your insurance company. Sometimes this office is required to provide additional clinical information such as treatment 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 door summaries, or copies of your entire Clinical Record. As this is the BHCTC’s model of treatmentIn such situations, this often works out welloffice will make every effort to release only the minimum information about you that is necessary for the purpose requested. 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 This information provided will become part of the your insurance company’s filesfiles and will probably be stored in a computer. Insurance Though all insurance companies are obligated claim to keep this such information confidential; however, please note that the BHCTC this office has no control over the handling of this what they do with such information by the insurance companyonce it is in their hands. If you receive treatment from one of our NJ Licensed PsychologistsIn some cases, your insurance company may share your information with a national medical information databank. This office will provide you with a copy of any report submitted by this office to your insurance company, if you request it. By signing that you authorize the psychologist read and reviewed this agreement, you agree that this office can provide requested information to disclose certain confidential information in order to obtain insurance coverage benefits for these servicesyour carrier. 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. It is also important to Please remember that you always have the right to pay for services directly yourself without seeking reimbursement through your treatment yourself insurance company to avoid any insurance issues discussed of the problems described above, including limited availability of benefits and/or the release of confidential information. MINORS & PARENTS. Patients under 18 years of age, who are not emancipated, and their parents should be aware that the law may allow parents to examine their child’s treatment records unless this office decides that such access is likely to injure the child or unless agreed otherwise. Privacy in counseling is crucial to successful progress, particularly with teenagers; it is this office’s policy to request an agreement from parents that they consent to give up their access to their child’s records. If parents agree, then during the course of treatment, this office will provide parents only general information about the progress of the child’s treatment and attendance at scheduled sessions. This office may also provide parents with a summary of their child’s treatment when it is complete, if requested. Any other communication will require the child’s authorization unless it is felt that the child is in danger or is a danger to someone else, in which case, the counselor will notify the parents of the concern. Before giving parents any information this office will discuss the matter with the child, if possible, and attempt to resolve any objections they may have. If there is any reason to question the custody status of a child patient, this office will require official documentation from the court that specifies what rights are held by which of the parents. This office will comply with these documents. This office provides clinical services and NOT forensic or custody evaluations. As such, this office will not take part in court actions or provide opinions related to custody issues. Such services are available elsewhere in the professional community and parents may be referred as appropriate. Requests by either parent, or parties involved with either parent, for this office to become involved in legal, forensic or custody evaluations may result in termination of services. QUESTIONS AND COMMENTS. Please feel free to discuss any questions or comments with your counselor.

Insurance Reimbursement. In order for you 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. Your provider will fill out required forms and provide you with assistance in receiving the benefits to which you are entitled; however, you (not your behavioral insurance company) are responsible for full payment of your xxxx. It is very important that you find out exactly what mental health treatments may be covered services your 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. Our office will provide you with any information we have based on our experience and will be happy to 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 in understanding the information you receive from your insurance company company. If your failure to obtain this authorization and/or receive it from comply with 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 requirements regarding choice of providers, authorizations, or other issues results in the denial of claims, you will be responsible for paying in full. If your diagnosiscoverage changes, it is your responsibility to notify our office and to comply with your new policy. You should also be aware that your contract with your health insurance company requires that we provide a clinical diagnosis and information about the reasons services provided to you. Sometimes your provider must provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, every effort will be made to release only the minimum information about you have sought treatment from that is necessary for the BHCTC, the symptoms you are suffering, and how long we believe treatment will or should continuepurpose requested. The This information provided will become part of the insurance company’s filescompany files and will probably be stored in a computer. Insurance Though all insurance companies are obligated claim to keep this such information confidential; however, please note that the BHCTC has we have no control over what they do with it once it is in their hands. In some cases, they may share the handling information with a national medical information databank. You will be provided with a copy of any report submitted if you request it. By signing the appropriate section of this Agreement, you agree to the provision of requested information by the insurance companyto your carrier. If you receive treatment from one need to file your own insurance, you may use either your statement or your encounter form. Please remember to include your policy information. Once we have all of our NJ Licensed Psychologiststhe information about your insurance coverage, 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 provider will discuss what our fees you can expect to accomplish with the benefits that are available and the best way for what will happen if they run out before you feel ready to arrange payment in order to receive continued treatment. If end 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 yousessions. It is also important to remember that you always have the right to pay for your treatment services yourself to avoid any insurance issues discussed abovethe problems described above [unless this is prohibited by contract].

Insurance Reimbursement. In order for us 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 may provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled, however, you (not your behavioral insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health treatments may be covered services your insurance policy covers. You should carefully read the section in whole or in part. The BHCTC will assist you in determining your insurance coverage and booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will be happy to help you fill out any forms neededin understanding the information you receive from your insurance company. Many managed care If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising cost 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 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 much can be accomplished in short-term therapy, some people clients feel that they need more services after their insurance benefits end. You should also be aware that your contract with your health insurance company requires that I provide them with information relevant to the service that I provide to you. If you have an Oregon insurance policy with the state law requirement that by accepting policy benefits, you are deemed to have consented to examination of your Clinical Record for purposes of utilization review, quality assurance and peer review by the insurance company, then I may provide clinical information to your insurer for such purposes. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probable be stored in a computer. Though all insurance companies claim to keep such information confidential, I have 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. I will provide you with a copy of any report I submit, if you request it. By signing this is Agreement, you agree that I can provide requested information to your carrier. Once we have all of the case with youinformation about your insurance coverage, we will discuss what our fees we can expect to accomplish with the benefits that are available and the best way for you what will happen if they run out before your feel ready to arrange payment in order to receive continued treatment. If end 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 yousessions. It is also important to remember that you always have the right to pay for your treatment my services yourself to avoid the problems described about [unless prohibited by contract]. You are protected under HIPAA. This law insures the confidentiality of all electronic transmission of information about you. Whenever I transmit information about you electronically (for example, sending emails or faxing information), I will be careful to insure confidentiality. If you elect to communicate with me by email at some point in our work together, please be aware that emails are not completely confidential. All emails are retained in the logs of our or my internet service provider (ISP). While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider. Any email I receive from you, and any insurance issues responses that I send to you, will be printed out and kept in your treatment record. My policy if you are in couples therapy If you and your partner decide to have some individual sessions as part of the couples therapy, what you say in those individual sessions will be considered to be a part of the couples therapy, and can and probably will be discussed in our joint sessions. Do not tell me anything you wish kept secret from your partner. I will remind you of this policy before beginning such individual sessions. Your signature below indicates that you have read this agreement and agree to its terms and also serves as an acknowledgment that you have received the HIPAA Notice from described above.

Insurance Reimbursement. In order for you 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. Your provider will fill out required forms and provide you with assistance in receiving the benefits to which you are entitled; however, you (not your behavioral insurance company) are responsible for full payment of your bill. It is very important that you find out exactly what mental health treatments may be covered services your 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. Our office will provide you with any information we have based on our experience and will be happy to 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 in understanding the information you receive from your insurance company company. If your failure to obtain this authorization and/or receive it from comply with 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 requirements regarding choice of providers, authorizations, or other issues results in the denial of claims, you will be responsible for paying in full. If your diagnosiscoverage changes, it is your responsibility to notify our office and to comply with your new policy. You should also be aware that your contract with your health insurance company requires that we provide a clinical diagnosis and information about the reasons services provided to you. Sometimes your provider must provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, every effort will be made to release only the minimum information about you have sought treatment from that is necessary for the BHCTC, the symptoms you are suffering, and how long we believe treatment will or should continuepurpose requested. The This information provided will become part of the insurance company’s filescompany files and will probably be stored in a computer. Insurance Though all insurance companies are obligated claim to keep this such information confidential; however, please note that the BHCTC has we have no control over what they do with it once it is in their hands. In some cases, they may share the handling information with a national medical information databank. You will be provided with a copy of any report submitted if you request it. By signing the appropriate section of this Agreement, you agree to the provision of requested information by the insurance companyto your carrier. If you receive treatment from one need to file your own insurance, you may use either your statement or your encounter form. Please remember to include your policy information. Once we have all of our NJ Licensed Psychologiststhe information about your insurance coverage, 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 provider will discuss what our fees you can expect to accomplish with the benefits that are available and the best way for what will happen if they run out before you feel ready to arrange payment in order to receive continued treatment. If end 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 yousessions. It is also important to remember that you always have the right to pay for your treatment services yourself to avoid any insurance issues discussed abovethe problems described above [unless this is prohibited by contract].

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 that it. You understand that, by using your insurance, you authorize the psychologist me to disclose certain confidential release such information in order to obtain your insurance coverage benefits for these servicescompany. This disclosure can occur only if it is pursuant I will try to a valid authorization and the keep that 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 youminimum necessary. It is also important to remember that paying for services yourself, without the use of insurance, avoids the problems described above SERtfICE DELItfERY 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 always 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 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 LIMITS ON CONFIDENTIALITY 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 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 pay for prevent me from providing any information about your treatment yourself 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 avoid any defend myself. ● If a patient uses health insurance issues discussed aboveHMO/PPO/EAP/MCO, disclosure of confidential information may be required by your health insurance carrier in order to process 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 I observe or have knowledge of an incident that reasonably appears to be physical abuse, 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 may be required to provide additional information.

Insurance Reimbursement. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. Please note that Xxxxx Xxxxxxxxx is an “Out-of-Network" provider. If you choose to file insurance, our office will gladly fill out a bill that will enable you to submit to current insurance carrier. Once you receive the claim forms from your insurance carrier you mail the bill I provided along with the claim form to your insurance company, who in turn, should mail you a check. We strongly recommend researching details about your mental health coverage. If you have a secondary health insuranceinsurance company, your behavioral health treatments may be covered in whole or in part. The BHCTC will assist you in determining your insurance you’ll need to find out that coverage and will help you fill the interactions with the first coverage. It’s helpful to find out any forms needed. Many managed care plans often require an authorization before treatment can begin. You may be required to contact specifics of your mental health coverage with your insurance company by asking questions such as: Is there a deductible? How many visits per year are covered? What are the dates of the benefit year? Which services are covered (e.g., couples therapy, group therapy)? You should also be aware that your contract with your health insurance company requires that this office provide it with information relevant to obtain this authorization and/or receive it from the services that your primary care physiciantherapist provides to you, including a clinical diagnosis. Many managed care Sometimes your therapist is required to provide additional clinical information such as treatment 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 or summaries, or copies of treatment, this often works out well. Where necessary, we may request more sessions from the managed care planyour entire Clinical Record. In order such situations, your therapist will make every effort to do so, we are typically required to complete release only the insurance company’s forms which may include providing your diagnosis, information about you that is necessary for the reasons you have sought treatment from the BHCTC, the symptoms you are suffering, and how long we believe treatment will or should continuepurpose requested. The This information provided will become part of the insurance company’s filescompany files and will probably be stored in a computer. Insurance Though all insurance companies are obligated claim to keep this such information confidential; however, please note that the BHCTC your therapist has no control over what they do with it. In some cases, they may share the handling information with a national medical information databank. Your therapist, Xxxxx Xxxxxxxxx, will provide you with a copy of any report submitted, if you request it. By signing this Agreement, you agree that your therapist can provide requested information to your insurance. Your therapist, Xxxxx Xxxxxxxxx, will gladly provide whatever assistance she can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of this information by the insurance companypractice’s fees. If you receive treatment from one of our NJ Licensed PsychologistsAlso, 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. It is also important to remember please note that you always have the right to pay for your treatment yourself services without seeking insurance reimbursement in order to avoid any insurance issues discussed abovethe problems described above (unless prohibited by contract).

Insurance Reimbursement. In order for us to set realistic treatment goals, 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. As a client, you (not your behavioral insurance company) are responsible for full payment of my fees and it is your responsibility to stay informed and keep me informed of any and all insurance coverage that you have, even and especially any secondary coverage you or a partner might possess. It is also your responsibility to inform me of and any changes made to your insurance or plan as soon as you know them. It is very important that you find out exactly what mental health treatments may be covered services your 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 or behavioral health services. If you have questions about the coverage, call your plan administrator. I will provide you with whatever information I can based on my experience and will be happy to help you fill out any forms neededin understanding the information you receive from your insurance company. Many managed care Due to 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 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 see 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 much can be accomplished in short-term therapy, some people patients feel that they need more services after their insurance benefits end. If You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire clinical record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this is Agreement, you agree that I can provide requested information to your carrier. Once we have all of the case with youinformation about your insurance coverage, we will discuss what our fees we can expect to accomplish with the benefits that are available and the best way for what will happen if they run out before you feel ready to arrange payment in order to receive continued treatment. If end 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 yousessions. It is also important to remember that you always have the right to pay for your treatment my services yourself to avoid any insurance the issues discussed described above.

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 our fees we can expect to accomplish with the benefits that are available and what will happen if the best way for insurance benefits run out before you feel ready to arrange payment in order to receive continued treatment. If end 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 yousessions. It is also important to remember that you always have the right to pay for your treatment our services yourself to and avoid any insurance issues discussed the complexities described above.

Insurance Reimbursement. In order for us to set realistic goals and priorities, it is important to evaluate what resources are available to pay for your therapy. If you have a health insurancebenefits policy, it will usually provide some coverage for mental health treatment. I do not participate on any insurance panels and thus your behavioral health treatments may treatment will likely be covered considered “out of network.” I will provide you with a receipt that includes the information insurance companies need to process your claim for reimbursement and you can opt to file your own claims. Remember that you, not your insurance company, are responsible for full payment of my fees. Please read carefully the section in whole or in part. The BHCTC will assist you in determining your insurance coverage booklet, which describes mental health services. If you have questions, you should call your plan and ask the insurance representative. I will, of course, provide whatever help I can in deciphering the information you get from your carrier about your coverage. The rising cost of health care has resulted in an increasing level of complexity about insurance benefits that sometimes makes it difficult to determine exactly how much mental health coverage is available. "Managed Health Care Plans" such as HMOs and PPOs often require advance authorization before they will provide reimbursement for mental health services. If you are planning to use your insurance to help pay for therapy with me, you fill out any forms neededwill want to ask your insurance representative if they cover my services. 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 are oriented towards a short-term treatment approach designed to work out resolve specific problems that prevent people from living and working as they normally domight be 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 somy 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 me to provide a diagnosis of mental illness. This diagnosis will become part of your permanent medical record. Sometimes additional clinical information such as a treatment plan or summary, or, in rare cases, a copy of the entire record is also required. 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, I have no control over what they do with it. In some cases they may share information with a national medical information data bank. If this is the case you request it, I will provide you with you, we will discuss what our fees are and the best way for you a copy of any report that I submit 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 youcarrier. It is also important to Please remember that you always have a choice to bypass the insurance altogether and pay a negotiated fee out of pocket. By signing this agreement you are giving me permission to release information requested by your carrier. Professional records I am required to keep appropriate records of the psychological services that I provide. Except in unusual circumstances that involve danger to yourself and/or others or the record makes reference to another person (unless the other person is a health care provider) and I believe the access is reasonably likely to cause substantial harm to such another person, you may examine or receive a copy of your Clinical record, if you request it in writing. Your Clinical record includes information about your reasons for seeking therapy, a description of the ways in which the problem impacts your life, your diagnosis, the goals that we set for treatment, your progress on those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of professional consultations, your billing records, and any reports that have been sent to anyone, including your insurance carrier. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason I recommend that you allow me to provide you with a treatment summary instead, or in the case that you wish to review your entire Clinical record, that you do so in my presence or in the presence of another mental health professional, so that you can discuss the contents. You should be aware that this will be treated in the same manner as any other professional service and you will be billed accordingly. Minors If you are under 18 years of age, please be aware that the law may provide your parents with the right to pay for examine your treatment records. Normally, I will provide them only with general information on how your treatment is proceeding. If, however, I feel that there is a high risk that you will seriously harm yourself or another, I will notify them of my concern. Before giving them any information I will try to avoid discuss the matter with you and will do the best I can to resolve any insurance issues discussed aboveobjections you might have about what I am prepared to discuss.

Insurance Reimbursement. In order for us to set realistic treatment goals and priorities, it is important to evaluate what re- sources 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. I will provide you with whatever as- sistance I can in helping you receive the benefits to which you are entitled; however, you (not your behavioral insurance company) are responsible for full payment of therapy fees. It is very important that you find out exactly what mental health treatments may be covered services your 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 I will provide you with whatever information I can based on my experience and will be happy to help you fill out any forms neededin understanding the information you receive from your insurance company. Many managed care If it is nec- xxxxxx to clear confusion, I am willing to call the 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 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-short- term therapy, some people clients feel that they need more services after their insurance benefits end. Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that most insurance companies require you to authorize me to provide them with youa clinical diagnosis. Sometimes I have 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 files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have 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. I will provide you with a copy of any report I submit, if you request it. Once we have all of the information about your insurance coverage, we will discuss what our fees we both can expect to accomplish with the benefits that are available and the best way for what will happen if they run out before you feel ready to arrange payment in order to receive continued treatment. If end 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 yousessions. It is also important to remember that you always have the right to pay for your treatment services yourself to avoid any the problems described above, unless prohibited by contract. If I am out-of-network with your insurance issues discussed abovecompany but have a PPO plan and you would like to use insurance coverage to pay for your therapy, I will provide you with a superbill. This superbill can then be submitted to your insurance company for reimbursement. Please be aware that if you choose to provide this receipt for services to your insurance company, it must include a psychi- atric diagnosis. In that event, I will inform you about the diagnosis that I plan to render before it is given. Any diagnosis that is made will become part of your permanent insurance records. A superbill is no guarantee of reimbursement. Even if you do not pursue reimbursement through your insurance company, a superbill may be useful for tax purposes or for utilizing funds set aside in an employer-based health savings account.