Common use of Insurance Reimbursement Clause in Contracts

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 benefits policy, it will usually provide some coverage for mental health treatment. You are responsible for any portion of the fees not covered by your insurance company. The general process is as follows: You pay your copay at time of session, your services are submitted to your insurance company, and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursed. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember that we try to work with insurance companies as a courtesy to you. We will follow up on claims for services rejected by your insurance company only three times. After three rejections, you will be responsible for payment in full. At that time, we will provide you with a superbill if you choose to continue to pursue reimbursement by your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing your insurance policy statements and Explanation of Benefits. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions, you should call your plan and inquire. The number for this inquiry is usually noted on the back of your insurance card at the bottom. Of course, we will provide you with whatever information we can, based on our experience and will be happy to try to assist you in deciphering the information you receive from your carrier. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before they will provide reimbursement for mental health services. These plans are often oriented towards a short-term treatment approach, designed to resolve specific problems that are interfering with one’s usual level of functioning. It may be necessary to seek additional approval after a certain number of sessions. In our experience, while quite a lot can be accomplished in short term therapy, many patients feel that more services are necessary after insurance benefits expire. You should also be aware that insurance agreements may require you to authorize us 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, we have no control over what they do with it. In some cases, they may share the information with a national medical information data bank. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself and avoid the complexities that are described above. Please note: Insurance rarely covers forensic psychology services.

Insurance Reimbursement. In order for us It is the patient’s responsibility to set realistic treatment goals verify my membership as a provider on his/her insurance plan, to know the expected amount of co-pay and prioritiesdeductible such plan requires to be met, it is important and to evaluate obtain a pre-authorization of services before the initial session, if required. Knowing what resources are available to pay for your treatment. If you have a health benefits policy, it will usually provide some coverage for policy requires and what mental health treatment. You are responsible for any portion of the fees not covered by your insurance company. The general process is as follows: You pay your copay at time of session, your services are submitted to your insurance company, and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method will be of reimbursing the patient for the fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursed. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember that we try to work with insurance companies as a courtesy great value to you. We will follow up on claims for services rejected by your insurance company only three times. After three rejections, you will be responsible for payment in full. At that time, we will provide you with a superbill if you choose You may want to continue to pursue reimbursement by your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing your insurance policy statements and Explanation of Benefits. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questionsquestions about your coverage, you should please call your plan administrator. If you have a health insurance policy for which I am a provider, my staff will file your insurance for you and inquirehelp you receive the benefits to which you are entitled. The You will be asked to pay your portion of the fee at each session. You will be billed for co-pays, deductibles, non-covered services and services deemed not medically necessary (i.e. un-kept appointments, testing, phone consultations, school consultation, conjoint sessions, family without patient sessions) as your claims are adjudicated. Tri-Care Members: You will be given paperwork to file your own claims. Since I am not a Tri-Care provider, I do not recognize assignments or discounts which reduce the patient’s share of the cost. As a Tri-Care patient, you will be expected to pay the full amount of the fee. Verification of insurance benefits does not guarantee payment for services. Payment depends on a number of factors including the beneficiary’s eligibility, benefit plan limitations and the coordination of benefits with other plans. Benefits under Managed Care insurance companies often must be pre-certified and deemed medically necessary by the clinical case manager. If my services are not considered medically necessary, you will be billed for these services (see paragraph one at top of this inquiry is usually noted on page) Initial: _____ Date: _____ At the back time of your initial session, you will be asked to bring your insurance card to verify your enrollment. If you do not present this card at the bottom. Of courseyour initial session, we your insurance will provide not be filed and you with whatever information we can, based on our experience and will be happy expected to try pay the full fee. Your insurance will be filed when our office is given this information. INFORMED CONSENT The purpose for therapy is for treatment only and not for making custody recommendations. As a clinician, it is my role to assist you provide treatment, and not to make recommendations to courts in deciphering domestic matters. It would be a dual relationship for me to provide clinical services to a family member and then to conduct a custody evaluation by making recommendations to the information you receive from your carrierCourt. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before they will provide reimbursement That would constitute a breach of professional ethics for mental health servicescounselors. These plans If you are often oriented towards involved in domestic litigation or become a short-term treatment approachparty to a divorce or custody action, designed you agree that you will not call me to resolve specific problems that are interfering with one’s usual level of functioningcourt to testify. It may be necessary to seek additional approval after a certain number of sessions. In our experience, while quite a lot can be accomplished in short term therapy, many patients feel that more services are necessary after insurance benefits expire. You should also be aware that insurance agreements may require you to authorize us 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, we Courts appoint professionals who have had no control over what they do with it. In some cases, they may share the information prior contact with a national medical information data bank. Once we have all of family to conduct custody evaluations and to make recommendations to the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits run out before you feel ready to end our sessionsCourt. It is important my policy not to remember testify in such cases, because experience has shown that the professional relationship is often harmed when counselors testify in divorce and custody cases. By signing this form, consenting to treatment, you always agree not to call me as a witness in domestic litigation. X ________ (initial by client) AUTHORIZATION AND ACKNOWLEDGEMENT I do hereby seek and consent to participate in evaluation and /or treatment. I have read the right above information and understand the contents. I agree to pay for professional services as they are received. If insurance is filed on my services yourself behalf, I agree to be financially responsible for any service provided which my insurance company may deem not medically necessary. I authorize Xxx Xxxxxxxx, X.Xx.xx release any information requested by my insurance carrier for the purpose of processing claims. I agree not to call you as a witness in domestic litigation. I have received information regarding the notice of privacy practices which explains how this office will use and avoid disclose my health information of the complexities that are described above. Please note: Insurance rarely covers forensic psychology servicespurposes of my treatment, payment for my treatment, and health care operations.

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 benefits policyinsurance policy that the provider participates with, it will usually provide provides some coverage for mental health treatmentservices. You We will submit claims on your behalf however, you (not your insurance company) are responsible for any portion full payment of our fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should be aware that your contract with your health insurance company requires that we provide them with information relevant to the services that is provide to you. We are required to provide a clinical diagnosis for reimbursement to occur. Sometimes we may be required to provide additional information such as treatment plans or therapy goals. By signing this agreement, you agree that we can provide requested information to your insurance carrier. Please be advised that you are fully responsible for the accuracy and timeliness of your insurance coverage. You acknowledge that if your insurance requires a referral or an authorization, you are responsible for obtaining that in order for your claims to be paid. By signing this agreement you agree to fully compensate Exhale Behavioral Health for all fees not covered reimbursed by your insurance company. The general process is as followsYOUR SIGNATURE/S BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS. IT ALSO MEANS THAT YOU HAVE READ AND UNDERSTAND THE ABOVE RISKS AND BENEFITS OF COUNSELING AND THAT YOU GIVE YOUR CONSENT TO PARTICIPATE IN TREATMENT. Client Name Client Signature Date Parent Name Parent Signature Date Parent(s)/legal guardian(s) agree to limit their access to my/our child’s clinical information except in these situations: You pay your copay at time Parent Signature Date I HAVE RECEIVED THE HIPAA PRIVACY POLICY (Notice of session, your services are submitted to your insurance company, Privacy Practices) Client Signature Date Parent Signature Date I understand the Exhale Behavioral Health’s policy for MISSED APPOINTMENTS and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursed. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember that we try to work with insurance companies as a courtesy to you. We will follow up on claims for services rejected by your insurance company only three times. After three rejections, you I will be responsible for payment in fulla fee of $75.00 if I do not provide 24 office hours notice of cancellation. At that time, we will provide you with a superbill if you choose to continue to pursue reimbursement by your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing your insurance policy statements and Explanation of Benefits. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions, you should call your plan and inquire. The number for this inquiry is usually noted on the back of your insurance card at the bottom. Of course, we will provide you with whatever information we can, based on our experience and will be happy to try to assist you in deciphering the information you receive from your carrier. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before they will provide reimbursement for mental health services. These plans are often oriented towards a short-term treatment approach, designed to resolve specific problems that are interfering with one’s usual level of functioning. It may be necessary to seek additional approval after a certain number of sessions. In our experience, while quite a lot can be accomplished in short term therapy, many patients feel that more services are necessary after insurance benefits expire. You should also be aware that insurance agreements may require you to authorize us 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, we have no control over what they do with it. In some cases, they may share the information with a national medical information data bank. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself and avoid the complexities that are described above. Please note: Insurance rarely covers forensic psychology services.Client Signature Date

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 benefits policy, it insurance policy that will usually provide cover some coverage for mental health treatment. You are responsible for any portion of the fees not covered by your insurance company. The general process is as follows: You pay your copay at time of session, your services are submitted to your insurance company, I will fill out forms and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursed. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember that we try to work with insurance companies as a courtesy to you. We will follow up on claims for services rejected by your insurance company only three times. After three rejections, you will be responsible for payment in full. At that time, we will provide you with a superbill if you choose to continue to pursue reimbursement by your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing your insurance policy statements and Explanation of Benefits. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions, you should call your plan and inquire. The number for this inquiry is usually noted on the back of your insurance card at the bottom. Of course, we will provide you with whatever information we canassistance I can in helping you receive the benefits to which you are entitled; however, based you (not your insurance company) are responsible for full payment of my fees. Your copay, co-insurance and/or deductible will be expected to be paid at the time of service and can be made by cash, check, on-line bill pay, or with credit/debit card through a link on our experience website: xxx.xxxxxxxxxxx.xxx. If paying by check, please make it out to Bluestone Psychological Services or BPS. It is very important that you find out exactly what mental health services your insurance policy covers and will be happy to try to assist you in deciphering the information you receive from your carrier. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before whether they will provide reimbursement cover services with me or not. Because plans are consistently changing, it is impossible for BPS to know the details of your individual plan. If it is necessary to clear confusion, please call your plan administrator. To qualify for coverage by your health insurance plan you must receive a mental health servicesdiagnosis. These plans This diagnosis indicates that your symptoms meet certain criteria and indicate a mental disorder. This information will become a permanent part of your medical record. While there are a great variety of mental health diagnoses indicating a wide range of impairment, insurance companies will only pay for certain ones. Treatment is also often oriented towards a limited to short-term treatment approach, approaches designed to resolve work out specific problems that are interfering interfere with onea person’s usual level of functioning. It may be necessary to seek additional approval for more therapy after a certain number of sessions. In our experience, while quite a lot It is not guaranteed that additional services will be authorized simply because we ask for them. The decision to reauthorize or not is entirely in the hands of your insurance company. Although much can be accomplished in short short-term therapy, many some patients feel that they need more services are necessary after insurance benefits expireend. You should also be aware In such cases, patients can continue treatment on a private pay basis. Your contract with your health insurance company requires that insurance agreements may require you I provide it with information relevant to authorize us the services that I provide to you. I am required to provide a clinical diagnosis, dates of services, types of services provided, and sometimes any copayments already received. Sometimes I am required to provide additional clinical information such as a treatment plan plans or summarysummaries, or in rare casescopies of your entire Clinical Record. In such situations, a copy of I will make every effort to release only the entire recordminimum information about you that is necessary for the purposes requested. This information will become part of the insurance company files, and in all probability, some of it will be computerizedpart of your medical record, and will probably be stored in a computer. All Though all insurance companies claim to keep such information confidential, but once it is in their hands, we I have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information data bankdatabank. Once we have all I will provide you with a copy of the any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information about to your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits run out before you feel ready to end our sessionscarrier. It is important to remember that you always have the right to pay for my services yourself and to avoid the complexities that are problems described above. Please noteUNPAID BALANCES AND RETURNED CHECKS If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collections agency or going through small claims court, which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name and contact information, the nature of services provided, the dates those services were rendered, and the amount due. If such legal action is necessary, its costs will be included in the claim. A $20 fee will be assessed for returned checks. Payment for the fee and unpaid balance must be made in cash, money order or by credit card before an additional session can be scheduled. LIMITS ON CONFIDENTIALITY The law attempts to protect the privacy of communications between a patient and a therapist. The Notice Form (found in the same place where you retrieved this form on our website: xxx.xxxxxxxxxxx.xxx) sets out how I use and disclosure your protected health information. I want to highlight that 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. With your signature on a proper Authorization form, I may disclose information in the following situations:  Disclosures required by health insurers or to collect overdue fees as discussed elsewhere in this Agreement.  If you are involved in a court proceeding and a request is made for information concerning the professional services I provided you, such information may be protected. I will seek your written authorization prior to disclosing any information. To prevent the disclosure of information, you must work with your attorney to secure a protective order against my compliance with a subpoena that has been properly served to me and of which you have been notified in a timely manner. However, I must comply with a court order requiring disclosure. If you are involved in or contemplating litigation, you should consult with your attorney about likely required court disclosures. There are some situations where I am permitted or required to disclose information without either your consent or Authorization:  If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.  If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.  If a patient files a worker’s compensation claim, and the services I am providing are relevant to the injury for which the claim was made, I must, upon appropriate request, provide a copy of the patient’s record to the patient’s employer and the Department of Labor and Industries. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice.  If I have reasonable cause to believe that a child has suffered abuse or neglect, the law requires that I file a report with the appropriate government agency, usually the Department of Social and Health Services. Once such a report is filed, I may be required to provide additional information.  If I have reasonable cause to believe that abandonment, abuse, financial exploitation or neglect of a vulnerable adult has occurred, the law requires that I file a report with the appropriate government agency, usually the Department of Social and Health Services. Once a report is filed, I may be required to provide additional information.  If I reasonably believe that there is an imminent danger to the health or safety of the patient or any other individual, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, seeking hospitalization for the patient, or contacting family members or others who can help provide protection. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. Although this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problems impact your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance that I conclude disclosure could reasonably be expected to cause danger to the life or safety of the patient or any other individual or the person who provided information to me in confidence under circumstances where confidentiality is appropriate, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most situations, I charge the per page amount authorized by the Department of Health. I may withhold your Record until the fees are paid. In addition, there are also times when I keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. Although the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they affect your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. These Psychotherapy Notes are kept separate from your Clinical Record. Although insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your signed, written Authorization. Insurance rarely covers forensic psychology services.companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your Psychotherapy Notes unless I determine that knowledge of the health care information would be injurious to your health or the health of another person, or could reasonably be expected to lead to your identification of an individual who provided the information in confidence and under circumstances in which confidentiality was appropriate, or contain information that was compiled and is used solely for litigation, quality assurance, peer review, or administrative purposes, or is otherwise prohibited by law. MINORS AND PARENTS I do not see minors in my clinical practice. YOUR SIGNATURE BELOW INDICATES THAT YOU HAV READ THIS AGREEMENT, AGREE TO ITS TERMS AND CONSENT TO TREATMENT. IT ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. Patient Signature Date Patient Signature (Couples Only) Date

Insurance Reimbursement. In order If you choose to use insurance you are responsible for us to set realistic treatment goals understanding your coverage and priorities, it is important to evaluate what resources are available to pay for letting me know if your treatmentcoverage changes. Authorization from your insurance company may be required before they will cover counseling fees. If you have a did not obtain authorization and it is required, you may be responsible for full payment of the fee. Only your insurance company has the authority to guarantee your benefits and eligibility for coverage. I strongly recommend contacting your insurance company prior to your first appointment or at any time you feel you require clarification regarding your policy to ensure you fully understand your coverage. You can do this by calling the number on your insurance card (usually located on the back). If you are covered by more than one health benefits policy, it will usually provide some coverage insurance policy you are responsible for mental health treatmentinforming me of your secondary policy if you wish to use it. You are responsible for any portion knowing which of the fees not covered by your insurance companypolicies is primary and which is secondary. The general process If you are unclear which of your policies is as follows: You pay your copay at time of session, your services are submitted to primary you should contact your insurance company, and you are then billed by BATT provider(s) in order to clarify the matter. If I am not a participating provider for any costs not covered by your insurance companyplan you may choose to use your out-of-network benefits. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is be aware not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursed. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember that we try to work with all insurance companies as a courtesy to you. We will follow up on claims reimburse for services rejected by your insurance company only three times. After three rejections, you will be responsible for payment in full. At that time, we will provide you with a superbill if you choose to continue to pursue reimbursement by your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing your insurance policy statements and Explanation of Benefits. You should carefully read the section in your insurance coverage booklet that describes mental health out-of-network services. If you have questions, choose to use your out-of-network benefits you should call will be required to pay the full fee at time of service. As a courtesy I may agree to submit an out-of-network claim on your plan behalf and inquirerequest any payment (if applicable) be sent directly to you. The number If I do not submit out-of-network claims for this inquiry is usually noted on the back you I will supply you with a receipt of payment for services which you may submit to your insurance card at the bottomcompany for reimbursement. Of course, we will provide If you with whatever information we can, based on our experience and will be happy prefer to try to assist use a participating provider I suggest you in deciphering the information you receive from contact your carrier. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before they will provide reimbursement for mental health services. These plans are often oriented towards a short-term treatment approach, designed to resolve specific problems that are interfering with one’s usual level of functioning. It may be necessary to seek additional approval after a certain number of sessions. In our experience, while quite a lot can be accomplished in short term therapy, many patients feel that more services are necessary after insurance benefits expire. You should also be aware that insurance agreements may require you to authorize us 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 for help locating a provider 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, we have no control over what they do with it. In some cases, they may share the information with a national medical information data bank. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself and avoid the complexities that are described above. Please note: Insurance rarely covers forensic psychology servicesnetwork.

Insurance Reimbursement. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources are you have available to pay for your treatment. If you have a health benefits insurance policy, it will usually provide some coverage for mental health treatment. You 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 responsible for any portion full payment of the fees not covered by your insurance company. The general process is as follows: You pay your copay at time of session, your services are submitted to your insurance company, and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursedmy fees. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember very important that we try to work with insurance companies as a courtesy to you. We will follow up on claims for you find out exactly what mental health services rejected by your insurance company only three times. After three rejections, you will be responsible for payment in full. At that time, we will provide you with a superbill if you choose to continue to pursue reimbursement by your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing your insurance policy statements and Explanation of Benefits. You should carefully read the section in your insurance coverage booklet that describes mental health servicescovers. If you have questionsquestions about the coverage, you should call your plan and inquire. The number for this inquiry is usually noted on the back of your insurance card at the bottom. Of course, we will provide you with whatever information we can, based on our experience and will be happy to try to assist you in deciphering the information you receive from your carrier. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before they will provide reimbursement for mental health services. These plans are often oriented towards a short-term treatment approach, designed to resolve specific problems that are interfering with one’s usual level of functioning. It may be necessary to seek additional approval after a certain number of sessions. In our experience, while quite a lot can be accomplished in short term therapy, many patients feel that more services are necessary after insurance benefits expireadministrator. You should also be aware that your contract with your health insurance agreements may require you company requires that I provide it with information relevant to authorize us the services that I provide to you. I am required to provide a clinical diagnosis and brief substantiation of that diagnosis, and sometimes . Sometimes I am required to provide additional clinical information. This information such as is limited to the dates of treatment and a treatment plan or summary, or in rare cases, a copy brief description of the entire recordservices provided, including the type of therapy provided. This information will become part of the insurance company files, files and will probably be stored in a computer. Though all probability, some of it will be computerized. All insurance companies claim to keep such information confidential, but once it is in their hands, we I have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information data bankdatabank. 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 to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits they run out before you feel ready to end our your sessions. It is important to remember that you always have the right to pay for my services yourself and to avoid the complexities that are problems described above. Please note: Insurance rarely covers forensic psychology Your signature on this agreement indicates your understanding that you are responsible for full payment of fees for my services.. You understand that if I submit claims to your insurance company, direct payment will be to Cedar Psychological Center. Any fees for services provided not covered by the insurance company will be your responsibility. You are responsible for paying applicable co-pays, co-insurance amounts, or deductibles at the time of service. It is also your responsibility to obtain all necessary referrals or authorizations required prior to treatment, and to ensure with your insurance company that I am a participating provider in your plan. I HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS. I ACKNOWLEDGE THAT I HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. I CONFIRM THAT I HAVE BEEN GIVEN THE OPPORTUNITY TO ASK QUESTIONS ABOUT THE ABOVE POLICIES AND MAY ASK ADDITIONAL QUESTIONS AT ANY TIME IN THE FUTURE. I CONSENT TO PARTICIPATE IN PSYCHOLOGICAL SERVICES OFFERED BY XX. XXXXX XXXXXX AT CEDAR PSYCHOLOGICAL CENTER. Rev. 07/16 Client Signature Date

Insurance Reimbursement. In order for us I am an in-network provider with many insurance providers. If you choose to set realistic treatment goals and prioritiesuse your insurance but your status changes, it is important your responsibility to evaluate what resources are available inform me as soon as possible so we can discuss any possible changes to pay for your treatmentpayment process. If you have switch to a health benefits policycompany with whom I am not in-network we will establish the best possible treatment plan for you, it which may include referring you to another in-network provider. When you choose to allow your insurance company to contribute payment to your treatment you do allow them access to your clinical records. I will usually be required to provide some coverage for mental health treatment. You are responsible for any portion of you with a diagnosis and share that diagnosis with the fees not covered by your insurance company. I will also be required to follow a treat- ment plan that relates to that diagnosis. Your insurance company may choose to deny or modify your treatment, based on their medical necessity criteria. Court Policy Please be advised that should I be requested to write a letter on any court related matter, I will NOT be stipulating in writing or in person as to an opinion. As your therapist, I may only provide observations and feedback. At no time will I make a recommendation in regards to custody or any other court related matter. If a court order is served and is requesting that I be present in person and/or there is a request for records, I will request your consent before turning over confidential information. I will discuss with you exactly what has been requested by court and there is no guarantee that the informa- tion will be kept confidential. This information includes mental health history, current status and inclusive records and may not be in your best interest. The general process therapist-client relationship does not render me as your advocate. I will withhold any opportunity to engage in a dual relationship in this way. Fees: Should I be ordered by court to write a letter to the court, the time shall be billed at $135.00 per hour. Should I be court ordered to appear in court, the fee stipulation is as follows: You pay your copay • $500 per day plus $20.00 per hour for travel to and from the court. • $50 per hour for preparation I will not be on-call at time of sessionany time. Should a case be trailed, your services are submitted I will be paid in full for each day as well as an additional $500.00per day as it hinders my ability to your insurance company, and you are then billed be available to other clients. All court fees must be received by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid cashier’s check 14 days prior to the doctor court date. Should the court calendar the hearing for another date, I must be re-issued a court order with the new court hearing date. Should I be on vacation, the party initiating the court order must take reasonable steps to avoid imposing undue burden or expense on a person subject to the subpoena. Consultation Disclosure There are times when I consult with other licensed mental health professionals about my cases. During these discussions, I make sure to disclose as little information as possible in order to protect your confidentiality. If I feel there is an instance when consultation may require more in- formation and may be helpful for our work together, I will talk with you beforehand about how to proceed. Collateral Involvement At times it is not a substitute for paymenthelpful to involve important people in your life in our work together. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursed. It If this is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember some- thing that we try to work with insurance companies as a courtesy to you. We will follow up on claims for services rejected by your insurance company only three times. After three rejections, you will be responsible for payment in full. At that time, we will provide you with a superbill if you choose to continue to pursue reimbursement by your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing your insurance policy statements and Explanation of Benefits. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions, you should call your plan and inquire. The number for this inquiry is usually noted on the back of your insurance card at the bottom. Of course, we will provide you with whatever information we can, based on our experience and will be happy to try to assist you in deciphering the information you receive from your carrier. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before they will provide reimbursement for mental health services. These plans are often oriented towards a short-term treatment approach, designed to resolve specific problems that are interfering with one’s usual level of functioning. It both feel may be necessary to seek additional approval after a certain number of sessions. In our experience, while quite a lot can be accomplished in short term therapy, many patients feel that more services are necessary after insurance benefits expire. You should also be aware that insurance agreements may require you to authorize us 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, we have no control over what they do with it. In some cases, they may share the information with a national medical information data bank. Once we have all of the information about your insurance coveragehelpful, we will discuss how much information you may be com- fortable disclosing and in what we can expect to accomplish way. I will never speak with the benefits that any of your family members about your treatment, or even confirm whether or not you are available and what will happen my client, without first having your writ- ten consent. One exception may be if the insurance benefits run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself and avoid the complexities that are described above. Please note: Insurance rarely covers forensic psychology servicesI am concerned about your safety.

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 benefits insurance policy, it will usually provide some coverage for mental health treatment. You are responsible for any portion of the fees not covered by your insurance company. The general process is as follows: You pay your copay at time of session, your services are submitted to your insurance company, and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursed. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember that we try to work with insurance companies as a courtesy to you. We will follow up on claims for services rejected by your insurance company only three times. After three rejections, you will be responsible for payment in full. At that time, we will provide you with a superbill if whatever assistance we can in helping you choose receive the benefits to continue to pursue reimbursement by which you are entitled; however, you (not your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing full payment of our fees. It is very important that you find out exactly what mental health services your insurance policy statements and Explanation covers. If we are not a provider for your specific insurance company, we will not be considered an “in network” provider; we will be considered an “out of Benefitsnetwork” provider. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questionsquestions about the coverage, you should call your plan and inquire. The number for this inquiry is usually noted on the back of your insurance card at the bottomadministrator. Of course, course we will provide you with whatever information we can, can based on our experience and experience. If it is necessary to reduce confusion, we will be happy willing to try call the company on your behalf. If we are a participating provider in your health insurance plan, you have already given our administrative staff permission by phone to assist contact your insurance company and verify your benefits. The payment you in deciphering make at the visit, known as a “copayment,” is specified by the insurance or managed care company. We are responsible for obtaining authorization for your visits and for submitting insurance claims. Your contract with your health insurance company requires that we disclose information you receive from your carrierrelevant to the services that we provide to you. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before they will provide reimbursement for mental health services. These plans We are often oriented towards a short-term treatment approach, designed to resolve specific problems that are interfering with one’s usual level of functioning. It may be necessary to seek additional approval after a certain number of sessions. In our experience, while quite a lot can be accomplished in short term therapy, many patients feel that more services are necessary after insurance benefits expire. You should also be aware that insurance agreements may require you to authorize us required to provide a clinical diagnosis, and sometimes . Sometimes we are required to provide additional clinical information such as a treatment plan plans or summarysummaries, or in rare casescopies of your entire Clinical Record. In such situations, a copy of we will make every effort to release only the entire recordminimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files, files and will probably be stored in a computer. Though all probability, some of it will be computerized. All insurance companies claim to keep such information confidential, but once it is in their hands, we have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information data bankdatabank. Once We will provide you with a copy of any report we have all of submit, if you request it. By signing the Acknowledgement Sheet, you agree that we can provide requested information about to your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself and avoid the complexities that are described above. Please note: Insurance rarely covers forensic psychology servicescompany.

Insurance Reimbursement. In order for us you and I to set realistic treatment goals and priorities, it is important to evaluate what resources are you have available to pay for your treatment. If you have a health benefits insurance policy, it will usually provide some coverage for mental health treatment. You are responsible for any portion of the fees not covered by your insurance company. The general process is as follows: You pay your copay at time of sessionAt my discretion, your services are submitted to your insurance company, I can fill out forms and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursed. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember that we try to work with insurance companies as a courtesy to you. We will follow up on claims for services rejected by your insurance company only three times. After three rejections, you will be responsible for payment in full. At that time, we will provide you with a superbill if you choose to continue to pursue reimbursement by your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing your insurance policy statements and Explanation of Benefits. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions, you should call your plan and inquire. The number for this inquiry is usually noted on the back of your insurance card at the bottom. Of course, we will provide you with whatever information we can, based on our experience and will be happy to try to assist you assistance needed in deciphering the information helping you receive from the benefits to which you are entitled; however, you (not your carrierinsurance company) are responsible for full payment of your fees. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before they will provide reimbursement for It is very important that you find out exactly what mental health services. These plans are often oriented towards a short-term treatment approach, designed to resolve specific problems that are interfering with one’s usual level of functioning. It may be necessary to seek additional approval after a certain number of sessions. In our experience, while quite a lot can be accomplished in short term therapy, many patients feel that more services are necessary after your insurance benefits expirepolicy covers. You should also be aware that your contract with your health insurance agreements may require you company requires that I provide it with information relevant to authorize us the services that I provide to you. I am required to provide a clinical diagnosis, and sometimes . Sometimes I am required to provide additional clinical information such as a treatment plan plans or summarysummaries, or in rare casescopies of our entire Clinical Record. In such situations, a copy of I will make every effort to release only the entire recordminimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files, files and will probably be stored in a computer. Though all probability, some of it will be computerized. All insurance companies claim to keep such information confidential, but once it is in their hands, we I have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information data bankdatabank. I can provide you with a copy of any report that I am required to submit, if you request it. Once we I have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits they run out before you feel ready to end our your sessions. It is important to remember that you always have the right to pay for my your services yourself and to avoid the complexities that are problems described aboveabove (unless prohibited by contract). Please note: initial here to acknowledge that you have read and understand the above section on Insurance rarely covers forensic psychology services.Reimbursement. _________________________ YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT IN ITS ENTIRETY AND AGREE TO ITS TERMS AS IT RELATES TO YOU AND/OR YOUR CHILD AS A CLIENT OF XXXXX X XXXXXX, PLLC AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA REQUIRED Notice of Policies and Practices to Protect the Privacy of Your Health Information AS DESCRIBED ABOVE. __________________________________________________________________________________________ Client Signature Print Name

Insurance Reimbursement. In order for us to set realistic treatment goals Insurance is a contract between you and priorities, it is important to evaluate what resources are available to pay for your treatment. If you have a health benefits policy, it will usually provide some coverage for mental health treatment. You are responsible for any portion of the fees not covered by your insurance company. The general process is as follows: You pay your copay at time of session, your services We are submitted to your insurance company, and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for paymentparty to this contract. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursed. It is We will bill your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember that we try to work with primary insurance companies company as a courtesy to you. We will follow up on claims for services rejected by Although we may estimate what your insurance company only three timesmay pay, it is the insurance company that makes the final determination of your eligibility. After three rejectionsYou agree to pay any portion of the charges not covered by insurance. Once again, it is important to understand that you will be are responsible for full payment in full. At that time, we will provide you with a superbill if you choose to continue to pursue reimbursement by of your account (not your insurance company). In many instancesIt is very important that you find out exactly what mental health services your insurance policy covers. Also, we are able to look up if your eligibility and benefits on websites provided by the insurance companies. Howeverrequires a pre- authorization, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing your obtaining it. Due to the rising costs of health care, insurance policy statements and Explanation of Benefitsbenefits have increasingly become more complex. You should carefully read the section in your insurance coverage booklet that describes It is sometimes difficult to determine exactly how much mental health servicescoverage is available. If you have questions, you should call your plan and inquire. The number for this inquiry is usually noted on the back of your insurance card at the bottom. Of course, we will provide you with whatever information we can, based on our experience and will be happy to try to assist you in deciphering the information you receive from your carrier. “Managed health care Health Care” plans such as HMOs and PPOs sometimes often require advance authorization before they will provide reimbursement for mental health services. These plans are often oriented towards a limited to short-term treatment approach, approaches designed to resolve work out specific problems that are interfering interfere with onea person’s usual level of functioning. It may be necessary to seek additional approval for more therapy after a certain number of sessions. In our experience, while quite a lot While much can be accomplished in short short- term therapy, many some patients feel that they need more services are necessary after insurance benefits expireend. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that your contract with your health insurance agreements may require you company requires that we provide it with information relevant to authorize us the services that are provided to you. We are required to provide a clinical diagnosis, and sometimes . Sometimes we are required to provide additional clinical information such as a treatment plan plans or summarysummaries, or in rare casescopies of your entire Clinical Record. In such situations, a copy of we will make every effort to release only the entire recordminimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files, files and will probably be stored in a computer. Though all probability, some of it will be computerized. All insurance companies claim to keep such information confidential, but once it is in their hands, we have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information data bankdatabank. We will provide you with a copy of any report we submit, if you request it. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits they run out before you feel ready to end our your sessions. It is important to remember that you always have the right to pay for my our services yourself and to avoid the complexities that are problems described above. Please note: Insurance rarely covers forensic psychology servicesabove unless prohibited by contract.

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 benefits insurance policy, it usually will usually provide some coverage for mental health treatment. I will provide you with whatever assistance I can in facilitating your receipt of the benefits you are entitled to receive. However, my relationship is with you, not your insurance company. You are responsible for any portion of the fees not covered by your insurance company. The general process is as follows: You pay your copay at time of session, your services are submitted to your insurance company, and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursedservice. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember important that we try to work with insurance companies as a courtesy to you. We will follow up on claims for you find out exactly what services rejected by your insurance company only three times. After three rejections, you will be responsible for payment in full. At that time, we will provide you with a superbill if you choose to continue to pursue reimbursement by your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing your insurance policy statements does and Explanation of Benefitsdoes not cover. You should carefully read the section information in your insurance coverage booklet that describes mental health servicesbooklet. If I will attempt to help you have questionsclarify insurance requirements and benefits information. With your consent, you should call your plan and inquire. The number for this inquiry is usually noted on the back of I will provide your insurance card at carrier with information that is necessary and appropriate in order to obtain maximum benefits. Some other points to keep in mind about health insurance include: • Some insurance requires pre-authorization. It is the bottomclient’s responsibility to obtain pre-authorization for services before the initial visit. Of courseIt is important to note that most companies do not backdate authorizations. Therefore, we will provide you with whatever information we canif this step is forgotten, based the client is liable for charges. I can not resubmit claims for dates of service prior to authorization, if preauthorization is required. • Insurance policies have limits on our experience and will be happy to try to assist you in deciphering the information you receive from your carrierpayment. Managed health Health care plans such as HMOs HMO’s and PPOs sometimes require advance authorization before they will provide reimbursement for mental health services. These plans PPO’s are often oriented towards a toward short-term treatment approach, approaches designed to resolve specific problems that are interfering interfere with one’s usual level of functioning. It Insurance may be not pay for all types of services. If pre-authorization is required for payment, it is necessary to seek receive additional approval from insurance to continue after a certain number of sessions. In our experience, while quite While a lot can be accomplished in short short-term therapy, many patients feel clients want or need services beyond those covered by their health insurance benefits. • Your contract with your health insurance company requires that more I provide information relevant to the services are necessary after insurance benefits expireI provide for you. You should also be aware that insurance agreements may require you to authorize us I am required to provide a clinical diagnosis. As previously addressed, and sometimes most managed care companies require that I provide additional clinical information such as a treatment plan plans or summary, summaries or in rare cases, a copy copies of the your entire clinical record. This In such situations, I will make efforts to release only the minimum information will become part of the insurance company files, and in all probability, some of it will be computerizedabout you that is requested. All insurance companies claim to keep such information confidential, but once it is in their hands, • When we have no control over what they do with it. In some cases, they may share the information with a national medical information data bank. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the these benefits that are available and what will happen if the insurance benefits they run out before you feel ready to end our your sessions. It is important to remember you have the right to self-pay. Filing Insurance Claims I file insurance claims as a courtesy to my clients. However all charges are the client’s responsibility. Working with your insurance company is a cooperative effort. Often it takes your calls to insurance representatives to make sure that claims are paid correctly and in a timely manner. It is also important that you notify me of any changes in your policy. Self Pay It is important to remember that you always have the right to pay for my services yourself and avoid the complexities that are problems with insurance described above. Please note: Insurance rarely covers forensic psychology This is really the only way to assure confidentiality and control over psychotherapy services. If you choose this option, I will discuss plans that can make this financially affordable. I appreciate the opportunity to be of profession service to you. I look forward to your questions and comments at any time. If you are satisfied with my services, I would appreciate you referring other people to me who might benefit from these services. My practice grows from your referrals.

Insurance Reimbursement. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources are you have available to pay for your treatment. If you have a health benefits insurance policy, it will usually provide some coverage for mental health treatment. You 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 responsible for any portion full payment of the fees not covered by your insurance company. The general process is as follows: You pay your copay at time of session, your services are submitted to your insurance company, and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursedmy fees. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember very important that we try to work with insurance companies as a courtesy to you. We will follow up on claims for you find out exactly what mental health services rejected by your insurance company only three times. After three rejections, you will be responsible for payment in full. At that time, we will provide you with a superbill if you choose to continue to pursue reimbursement by your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing your insurance policy statements and Explanation of Benefits. You should carefully read the section in your insurance coverage booklet that describes mental health servicescovers. If you have questionsquestions about the coverage, you should call your plan and inquire. The number for this inquiry is usually noted on the back of your insurance card at the bottom. Of course, we will provide you with whatever information we can, based on our experience and will be happy to try to assist you in deciphering the information you receive from your carrier. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before they will provide reimbursement for mental health services. These plans are often oriented towards a short-term treatment approach, designed to resolve specific problems that are interfering with one’s usual level of functioning. It may be necessary to seek additional approval after a certain number of sessions. In our experience, while quite a lot can be accomplished in short term therapy, many patients feel that more services are necessary after insurance benefits expireadministrator. You should also be aware that your contract with your health insurance agreements may require you company requires that I provide it with information relevant to authorize us the services that I provide to you. I am required to provide a clinical diagnosis and brief substantiation of that diagnosis, and sometimes . Sometimes I am required to provide additional clinical information. This information such as is limited to the dates of treatment and a treatment plan or summary, or in rare cases, a copy brief description of the entire recordservices provided, including the type of therapy provided. This information will become part of the insurance company files, files and will probably be stored in a computer. Though all probability, some of it will be computerized. All insurance companies claim to keep such information confidential, but once it is in their hands, we I have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information data bankdatabank. 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 to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits they run out before you feel ready to end our your sessions. It is important to remember that you always have the right to pay for my services yourself and to avoid the complexities that are problems described above. Please note: Insurance rarely covers forensic psychology Your signature on this agreement indicates your understanding that you are responsible for full payment of fees for my services.. You understand that if I submit claims to your insurance company, direct payment will be to Cedar Psychological Center. Any fees for services provided not covered by the insurance company will be your responsibility. You are responsible for paying applicable co-pays, co-insurance amounts, or deductibles at the time of service. It is also your responsibility to obtain all necessary referrals or authorizations required prior to treatment, and to ensure with your insurance company that I am a participating provider in your plan. I HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS. I ACKNOWLEDGE THAT I HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. I CONFIRM THAT I HAVE BEEN GIVEN THE OPPORTUNITY TO ASK QUESTIONS ABOUT THE ABOVE POLICIES AND MAY ASK ADDITIONAL QUESTIONS AT ANY TIME IN THE FUTURE. I CONSENT TO PARTICIPATE IN PSYCHOLOGICAL SERVICES OFFERED BY XX. XXXXX XXXXXX AT CEDAR PSYCHOLOGICAL CENTER. Client Signature Date

Insurance Reimbursement. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources are you have available to pay for your treatment. If you have a health benefits insurance policy, it will usually provide some coverage for mental health treatment. You are responsible for any portion of the fees not covered by your insurance company. The general process is as follows: You pay your copay at time of session, your services are submitted to your insurance company, and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursed. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember that we try to work with insurance companies as a courtesy to you. We will follow up on claims find out exactly what mental health services are covered for services rejected you by your insurance company only three times. After three rejectionspolicy, you will and whether treatment needs to be responsible for payment in full. At that time, we will provide you with a superbill if you choose to continue to pursue reimbursement by your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing your insurance policy statements and Explanation of Benefits. You should carefully read the section in your insurance coverage booklet that describes mental health servicespre-authorized. If you have questionsquestions about the coverage, you should call your plan and inquire. The number for this inquiry is usually noted on the back of your insurance card at the bottomadministrator. Of course, we I will provide you with whatever information we can, I can based on our my experience and will be happy to try to assist help you in deciphering understanding the information you receive from your carrier. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before they will provide reimbursement for mental health services. These plans are often oriented towards a short-term treatment approach, designed to resolve specific problems that are interfering with one’s usual level of functioning. It may be necessary to seek additional approval after a certain number of sessions. In our experience, while quite a lot can be accomplished in short term therapy, many patients feel that more services are necessary after insurance benefits expirecompany. You should also be aware that most insurance agreements may companies require you to authorize us me to provide them with a code number that indicates a clinical diagnosis. The insurance company will sometimes ask for more information including symptoms, diagnoses, degree of impairment, and sometimes additional clinical my treatment methods. This will become part of your permanent medical record. I will let you know if this situation should arise. Please understand that I have no control over how these records are handled at the insurance company. My policy is to provide only as much information such as a treatment plan or summary, or in rare cases, a copy of the entire recordinsurance company needs to pay your benefits. This information will become part of the insurance company files, files and will probably be stored in a computer. Though all probability, some of it will be computerized. All insurance companies claim to keep such information confidential, but once it is in their hands, we I have no control over what they do with it. In some cases, they may share the information with a national medical information data bankit once it is in their hands. Once we you have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available available, and what will happen if the insurance benefits they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself and to avoid the complexities that are problems described above. Please note: Insurance rarely covers forensic psychology servicesnote that the insurance contract is between you and your insurance company and the responsibility for your fees is yours. Consequently, disputes concerning coverage must be resolved by you with your insurance carrier. Further, even though payment may be sent from the insurance company directly to me, it is your responsibility for any balance not covered by your insurance. Unpaid bills may be turned over to a collection agency and/or an attorney and, if so, you will also be responsible for collection and/or legal costs.

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 benefits policy, it will usually provide some coverage for plan to use out-of-network mental health treatmentcoverage, we will fill out any necessary forms required of your insurance and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled. You However, you (and not your insurance provider) are responsible for any portion full payment of our fees at the fees not covered by end of each session. Our session fee is $170/session. Your insurance will then reimburse you if they cover your insurance company. The general process is as follows: You pay your copay at time of session, your services are submitted to your insurance company, and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursedsessions. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember that we try to work with insurance companies as a courtesy to you. We will follow up on claims for find out exactly what mental health services rejected by your insurance company only three times. After three rejections, you will be responsible for payment in full. At that time, we will provide you with a superbill if you choose to continue to pursue reimbursement by your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing your insurance policy statements and Explanation of Benefits. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions, you should call your plan and inquire. The number for this inquiry is usually noted on the back of your insurance card at the bottom. Of course, we will provide you with whatever information we can, based on our experience and will be happy to try to assist you in deciphering the information you receive from your carrier. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before they will provide reimbursement for mental health services. These plans are often oriented towards a short-term treatment approach, designed to resolve specific problems that are interfering with one’s usual level of functioning. It may be necessary to seek additional approval after a certain number of sessions. In our experience, while quite a lot can be accomplished in short term therapy, many patients feel that more services are necessary after insurance benefits expirecovers. You should also be aware that your contract with your health insurance agreements may require you company requires that we provide it with information relevant to authorize us the services provided to you. We are required to provide a clinical diagnosis, and sometimes . Sometimes we are required to provide additional clinical information such as a treatment plan plans or summarysummaries, or in rare casescopies of your entire Clinical Record. In such situations, a copy of we will make every effort to release only the entire recordminimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files, files and will probably be stored in a computer. Though all probability, some of it will be computerized. All insurance companies claim to keep such information confidential, but once it is in their hands, we have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information data bankdatabank. We will provide you with a copy of any report we submit, if you request it. By signing this Agreement, you agree that we can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits they run out before you feel ready to end our your sessions. It is important to remember that you always have the right to pay for my our services yourself and to avoid the complexities that are problems described above. Please note: Patient Rights HIPAA (Health Insurance rarely covers forensic psychology servicesPortability and Accountability Act) provides you with several new or expanded rights with regard to your clinical records and disclosures of protected health information. These rights include requesting that your doctor amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and our privacy policies and procedures.

Insurance Reimbursement. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources are you have available to pay for your treatment. If you have a health benefits insurance policy, it will usually provide some coverage for mental health treatment. You 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 responsible for any portion full payment of the my fees not covered by your insurance company. The general process is as follows: You pay your copay at time of session, your services are submitted to your insurance company, and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursed/ contracted rate. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember very important that we try to work with insurance companies as a courtesy to you. We will follow up on claims for you find out exactly what mental health services rejected by your insurance company only three times. After three rejections, you will be responsible for payment in full. At that time, we will provide you with a superbill if you choose to continue to pursue reimbursement by your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing your insurance policy statements covers and Explanation of Benefitsreceive the necessary authorizations prior to your first appointment. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questionsquestions about the coverage, you should call your plan and inquire. The number for this inquiry is usually noted on the back of your insurance card at the bottomadministrator. Of course, we course I will provide you with whatever information we can, I can based on our experience and my experience. I will be happy to try to assist help you in deciphering understanding the information you receive from your carrierinsurance company. If it is necessary to clear confusion, I will be 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 Health Care” plans such as HMOs and PPOs sometimes often require advance authorization before they will provide reimbursement for mental health services. These plans are often oriented towards a limited to short-term treatment approach, approaches designed to resolve work out specific problems that are interfering interfere with onea person’s usual level of functioning. It may be necessary to seek additional approval for more therapy after a certain number of sessions. In our experience, while quite While a lot can be accomplished in short short-term therapy, many some patients feel that they need more services are necessary after insurance benefits expireend. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. Please note the benefits, copayments, coinsurance and deductibles that are quoted to you are only an estimate based on the information available and not a guarantee of payment. Reimbursement is based on Medical Necessity and subject to policy guidelines, contract limitations and eligibility at the time of service. You should also be aware that most insurance agreements may companies require you to authorize us me to provide them with a clinical diagnosis, and sometimes . Sometimes I have to provide additional clinical information such as a treatment plan plans or summarysummaries, or copies of the entire record (in rare cases, a copy of the entire record). This information will become part of the insurance company files, files and will probably be stored in a computer. Though all probability, some of it will be computerized. All insurance companies claim to keep such information confidential, but once it is in their hands, we I have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information data bankdatabank. Once we have all I will provide you with a copy of the information about your insurance coverageany report I submit, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself and avoid the complexities that are described above. Please note: Insurance rarely covers forensic psychology servicesrequest.

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 insurance policy for which I am a provider, my staff will fill out forms and help you receive the benefits policyto which you are entitled; however, it will usually provide some coverage for mental health treatment. You you are responsible for any portion full payment of the fees not covered by your insurance company. The general process is as follows: You pay your copay at time of session, your services are submitted to your insurance company, and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursedmy fees. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember very important that we try to work with insurance companies as a courtesy to you. We will follow up on claims for you find out exactly what mental health services rejected by your insurance company only three times. After three rejections, you will be responsible for payment in full. At that time, we will provide you with a superbill if you choose to continue to pursue reimbursement by your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing your insurance policy statements and Explanation of Benefitscovers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questionsquestions about coverage, you should call your plan administrator. Verification of insurance benefits does not guarantee payment for services. Payment depends on a number of factors including the beneficiary’s eligibility, benefit plan limitations and inquirethe coordination of benefits with other plans. The number for this inquiry is usually noted on Benefits under Managed Care insurance companies often must be pre-certified and deemed medically necessary by the back of your insurance card at the bottomclinical case manager. Of courseIf my services are not considered medically necessary, we will provide you with whatever information we can, based on our experience and will be happy to try to assist you in deciphering the information you receive from your carrier. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before they will provide reimbursement billed for mental health these services. These plans are often oriented towards a short-term treatment approachSuch services may include conjoint sessions for adults and/or families, designed to resolve specific problems that are interfering with one’s usual level of functioning. It may be necessary to seek additional approval after a certain number of family without patient sessions. In our experience, while quite a lot can be accomplished in short term therapy, many patients feel that more services are necessary after insurance benefits expire. You should also be aware that insurance agreements may require you to authorize us to provide a clinical diagnosis, and sometimes additional clinical school consultations/observations. Authorization and Acknowledgement I do hereby seek and consent to participate in evaluation and/or treatment. I have read the above information such as a treatment plan or summary, or in rare cases, a copy of and understand the entire recordcontents. 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, we have no control over what they do with it. In some cases, they may share the information with a national medical information data bank. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits run out before you feel ready to end our sessions. It is important to remember that you always have the right I agree to pay for professional services as they are received. If insurance is filed on my services yourself behalf, I agree to be financially responsible for any service provided which my insurance company may deem not medically necessary. I authorize to release any information requested to my insurance carrier for the purpose of processing claims. I agree not to call you as a witness in domestic litigation. I have received information regarding the notice of privacy practices which explains how this office will use and avoid disclose my health information of the complexities that are described abovepurposes of my treatment, payment for my treatment, and health care operations. Please note: Insurance rarely covers forensic psychology services.Patient’s full legal name (print) Signature of patient or legally authorized representative and relationship to patient

Insurance Reimbursement. 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 for us to set realistic treatment goals and priorities, it is important to evaluate what resources are you have available to pay for your treatment. It is very important that you find out exactly what mental health services your insurance policy covers as soon as possible. It is your responsibility to contact your insurance company to verify your coverage and benefits for mental health treatment. If you have a health benefits insurance policy, it will usually may or may not provide some coverage for mental health treatment. You are responsible for any portion of the fees not covered by your insurance company. The general process is as follows: You pay your copay at time of session, your services are submitted to your insurance company, and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursed. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember that we try to work with insurance companies as a courtesy to you. We will follow up on claims for services rejected by your insurance company only three times. After three rejections, you will be responsible for payment in full. At that time, we will provide you with a superbill if you choose to continue to pursue reimbursement by your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing your insurance policy statements and Explanation of Benefits. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questionsquestions about the coverage, you should call your plan and inquireadministrator. The number for this inquiry is usually noted on the back of your insurance card at the bottom. Of course, we This office will provide you with whatever information we canassistance, based on our experience and will be happy if possible, (for example providing required treatment plans) to try to assist you in deciphering the information help you receive from the benefits to which you are entitled; however, you (not your carrier. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before they will provide reimbursement insurance company) are responsible for mental health services. These plans are often oriented towards a short-term treatment approach, designed to resolve specific problems that are interfering with onefull payment of this office’s usual level of functioning. It may be necessary to seek additional approval after a certain number of sessions. In our experience, while quite a lot can be accomplished in short term therapy, many patients feel that more services are necessary after insurance benefits expire. You should also be aware that insurance agreements may require you to authorize us 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, we have no control over what they do with it. In some cases, they may share the information with a national medical information data bankfees. Once we have this office has all of the information about your insurance coverage, we your counselor will discuss with you what we you can expect to accomplish with the benefits that are available and what will happen if the insurance benefits they run out before you feel ready to end our your sessions. It 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 important required to provide a clinical diagnosis to your insurance company. Sometimes this office is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, this office 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 your insurance company’s files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, this office has no control over what they do with such information once it is in their hands. In 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 read and reviewed this agreement, you agree that this office can provide requested information to your carrier. Please remember that you always have the right to pay for my services directly yourself and without seeking reimbursement through your insurance company to avoid any of the complexities that are problems described above, including limited availability of benefits and/or the release of confidential information. Please note: Insurance rarely covers 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 psychology 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.

Insurance Reimbursement. In order for us to set realistic treatment goals Your health insurance policy is a contract between you and priorities, it is important to evaluate what resources are available to pay for your treatment. If you have a health benefits policy, it will usually provide some coverage for mental health treatment. You are responsible for any portion of the fees not covered by your insurance company; I am not a party in that contract. The general process Collection of insurance benefits or any other arrangement regarding third party payment is as follows: You pay your copay at time of session, your services are submitted responsibility. I would be considered an out-of-network provider to your insurance company, many insurers and you will need to inquire about your benefits regarding this. At this time, I am not contracting directly with insurance companies as a network provider so I am responsible and accountable only to you. Thus, my loyalties are then billed by BATT not divided and there is no conflict of interest. I will give you a receipt for any costs not covered by your insurance company. Please remember that insurance is considered specify if you intend to submit a method of reimbursing the patient for the fee paid claim due to the doctor and extra information required for insurance reimbursement -- including a mental health diagnostic code. Additionally, you may want to find out if your insurer will require me to provide them with any detailed information about you. You may understandably elect not to use your insurance to protect your confidentiality or to avoid any label they may require. Confidentiality, HIPAA, & Limitations: I will not discuss the details of your/your child/family’s situation or any issues we talk about (or release information to any third party) without your specific permission to do so. One of the strengths of the counseling relationship is not a substitute for payment. Some companies pay fixed allowances for certain proceduresthe freedom that you have to discuss your feelings, actions, and needs related to you/your child/family without concern that others pay a percentage might learn about you through me. I am bound by the ethical code of the chargemy profession to protect this confidential relationship. Testing services The Health Insurance Portability And Accountability Act Of 1996 (commonly known as HIPAA) provides specific protections which are not always reimbursed. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember that we try to work with insurance companies as a courtesy detailed in an additional document I can provide to you. We will follow up Please be aware that the intent of HIPAA is to clarify the processes by which private health information is passed among different parties, and focuses on claims for services rejected by your insurance company only three timesthe entire health care profession (physicians, laboratories, hospitals, agencies, etc.). After three rejections, you will be responsible for payment Many of the guidelines do not apply directly to a social worker in full. At that time, we will provide you with a superbill if you choose to continue to pursue reimbursement by your insurance companyprivate practice. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. Howeverfact, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote obligations I have to you as your eligibility and benefits (based on a function of the website information) and what the insurance companies actually pay on your behalfsocial work profession’s code of ethics are generally more restrictive than those found in HIPAA. YOU are responsible for reviewing your insurance policy statements and Explanation of Benefits. You should carefully read the section in your insurance coverage booklet that describes mental health services. If Nevertheless, please let me know if you have questions, you should call your plan and inquire. The number for this inquiry is usually noted on Limitations to the back rules of your insurance card at the bottom. Of course, we will provide you with whatever information we can, based on our experience and will be happy to try to assist you in deciphering the information you receive from your carrier. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before they will provide reimbursement for mental health services. These plans confidentiality are often oriented towards a short-term treatment approach, designed to resolve specific problems that are interfering with one’s usual level of functioning. It may be necessary to seek additional approval after a certain number of sessions. In our experience, while quite a lot can be accomplished in short term therapy, many patients feel that more services are necessary after insurance benefits expire. You should also be aware that insurance agreements may require you to authorize us 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, we have no control over what they do with it. In some cases, they may share the information with a national medical information data bank. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself and avoid the complexities that are described above. Please note: Insurance rarely covers forensic psychology services.listed below:

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 benefits insurance policy, it will usually provide some at least partial coverage for mental health treatment. You are responsible for any portion of the fees not covered by your insurance company. The general process is as follows: You pay your copay at time of session, your services are submitted to your insurance company, and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursed. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember that we try to work with insurance companies as a courtesy to youPsychological Evaluation. We will follow up on claims for services rejected by your insurance company only three times. After three rejections, you will be responsible for payment in full. At that time, we will provide you with a superbill if whatever assistance we can in helping you choose receive the benefits to continue to pursue reimbursement by which you are entitled; however, you (not your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing full payment of our fees. It is very important that you find out exactly what mental health services your insurance policy statements and Explanation of Benefitscovers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questionsquestion about coverage, you should call your the plan and inquireadministrator. The number for this inquiry is usually noted on the back of your insurance card at the bottom. Of course, we We will provide you with whatever information we can, can based on our experience and will be happy to try to assist help you in deciphering understanding the information you receive from your carrierinsurance company. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before they will provide reimbursement for mental health services. These plans are often oriented towards a short-term treatment approach, designed to resolve specific problems that are interfering with one’s usual level of functioning. It may be If it is necessary to seek additional approval after clear confusion, we will be willing to call the company on your behalf. Your signature on this Agreement verifies that you understand that our preauthorization for this evaluation is not a certain number of sessionsguarantee that your insurance company will pay for this evaluation. In our experienceIf your insurance company chooses not to pay, while quite a lot can be accomplished in short term therapy, many patients feel that more services are necessary after insurance benefits expireyou have agreed to pay out-of-pocket for this evaluation based on the rates listed below. You should also Please be aware that most insurance agreements may companies require providers to supply a clinical diagnosis for reimbursement purposes. By signing this agreement, you to authorize us to provide a clinical diagnosiscomply with this requirement. Occasionally, and sometimes additional clinical information such as a treatment plan or summaryplans, summaries, or in rare casescopies of the entire record are required. Upon request, we will provide you with a copy of any report we submit. Emergency Procedures and Contact Information We do not provide 24-hour phone coverage. We will return your call within one business day, with the entire record. This information will become part exception of the insurance company files, holidays 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, we have no control over what they do with itvacations. In some casesan emergency, they may share call 911 or obtain safe transportation to the information with a national medical information data bank. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself and avoid the complexities that are described above. Please note: Insurance rarely covers forensic psychology servicesnearest hospital emergency room.

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 benefits policyinsurance policy that the provider participates with, it will usually provide provides some coverage for mental health treatmentservices. You We will submit claims on your behalf however, you (not your insurance company) are responsible for any portion full payment of our fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should be aware that your contract with your health insurance company requires that we provide them with information relevant to the services that is provide to you. We are required to provide a clinical diagnosis for reimbursement to occur. Sometimes we may be required to provide additional information such as treatment plans or therapy goals. By signing this agreement, you agree that we can provide requested information to your insurance carrier. Please be advised that you are fully responsible for the accuracy and timeliness of your insurance coverage. You acknowledge that if your insurance requires a referral or an authorization, you are responsible for obtaining that in order for your claims to be paid. By signing this agreement you agree to fully compensate Exhale Behavioral Health for all fees not covered reimbursed by your insurance company. The general process is as followsYOUR SIGNATURE/S BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS. IT ALSO MEANS THAT YOU HAVE READ AND UNDERSTAND THE ABOVE RISKS AND BENEFITS OF COUNSELING AND THAT YOU GIVE YOUR CONSENT TO PARTICIPATE IN TREATMENT. Client Name Client Signature Date Parent Name Parent Signature Date Parent(s)/legal guardian(s) agree to limit their access to my/our child’s clinical information except in these situations: You pay your copay at time Parent Signature Date I HAVE RECEIVED THE HIPAA PRIVACY POLICY (Notice of session, your services are submitted to your insurance companyPrivacy Practices) Client Signature Date Parent Signature Date I understand the Exhale Behavioral Health’s policy for MISSED APPOINTMENTS AND CANCELATIONS, and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursed. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember that we try to work with insurance companies as a courtesy to you. We will follow up on claims for services rejected by your insurance company only three times. After three rejections, you I will be responsible for payment in fulla fee of $100.00 if I do not notify the office by 3:00 the previous business day. At that time, we will provide you with a superbill if you choose to continue to pursue reimbursement by your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing your insurance policy statements and Explanation of Benefits. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions, you should call your plan and inquire. The number for this inquiry is usually noted on the back of your insurance card at the bottom. Of course, we will provide you with whatever information we can, based on our experience and will be happy to try to assist you in deciphering the information you receive from your carrier. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before they will provide reimbursement for mental health services. These plans are often oriented towards a short-term treatment approach, designed to resolve specific problems that are interfering with one’s usual level of functioning. It may be necessary to seek additional approval after a certain number of sessions. In our experience, while quite a lot can be accomplished in short term therapy, many patients feel that more services are necessary after insurance benefits expire. You should also be aware that insurance agreements may require you to authorize us 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, we have no control over what they do with it. In some cases, they may share the information with a national medical information data bank. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself and avoid the complexities that are described above. Please note: Insurance rarely covers forensic psychology services.Client Signature Date

Insurance Reimbursement. In order for us to set realistic treatment goals and priorities, it Insurance billing is important to evaluate what resources are available to pay for your treatment. If you have a health benefits policy, it will usually provide some coverage for mental health treatment. You are responsible for any portion of the fees not covered by your insurance company. The general process is as follows: You pay your copay at time of session, your services are submitted to your insurance company, and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursed. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember that we try to work with insurance companies as a courtesy to you. We will follow up on claims for services rejected by only possible if your insurance company only three timeswill pay for the services of a registered intern. After three rejectionsIf so, you all documents will usually have to be responsible for payment in fullsigned by my supervisor and me. At that time, we I will provide you with a superbill if you choose to continue to pursue reimbursement by statement for your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state company so that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing your insurance policy statements and Explanation of Benefits. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions, you should call your plan and inquiremay receive reimbursement. The number for this inquiry is usually noted on the back information may include dates of your insurance card at the bottom. Of courseappointment, we will provide you with whatever information we can, based on our experience and will be happy to try to assist you in deciphering the information you receive from your carrier. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before they will provide reimbursement for mental health services. These plans are often oriented towards a short-term treatment approach, designed to resolve specific problems that are interfering with one’s usual level of functioning. It may be necessary to seek additional approval after a certain number of sessions. In our experience, while quite a lot can be accomplished in short term therapy, many patients feel that more services are necessary after insurance benefits expire. You should also be aware that insurance agreements may require you to authorize us to provide a clinical diagnosis, and sometimes a treatment summary. I ask that you pay for your treatment up front. It is my policy to write statements for reimbursements on a monthly basis. Sometimes I have to provide additional clinical information such as a treatment plan plans or summarysummaries, or copies of the entire record (in rare cases). Legal Involvements As a general policy, a copy I do not to get involved in court proceedings and/or write recommendations to the court system including mediators, custody evaluators, attorneys, etc. If you need such services, I may not be right match for you. Termination of the entire recordTherapy In our initial sessions, you and I should pay careful attention to whether or not we feel comfortable working together. This information will become In addition, 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, we have no control over what they do with it. In some cases, they may share the information with a national medical information data bank. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen my responsibility includes assessing if the insurance benefits run out before services I am offering can be helpful to you. If you feel ready have any questions about my work or procedures, please discuss them with me whenever they arise. If your doubts persist, you are free to end our sessionsseek an opinion from another mental health professional or to terminate therapy at any time. It is important to remember that you always have I reserve the right to pay terminate therapy at my discretion. Reasons for termination include, but are not limited to, untimely payment of fees, failure to comply with treatment recommendations, conflicts of interest, failure to participate in therapy, a client’s needs are outside of my scope of competence or practice, or a client is not making adequate progress in therapy. If either of us decides to terminate therapy, I will generally recommend that you participate in at least one, or possibly more, termination sessions. These sessions are intended to facilitate a positive termination experience and give both of us an opportunity to reflect on the work that has been done. I will also attempt to ensure a smooth transition to another therapist by offering referrals. Therapist Availability I am not available 24/7. When I am unavailable, feel free to leave a message on my answering machine. I will make every effort to return your call within 24hrs, with the exception of weekends and holidays. I am unable to provide 24-hour crisis service. To speak with a crisis counselor you may call the 24 hour Suicide/Crisis Hotline at: (000) 000-0000. In the event that you are feeling unsafe or require immediate medical or psychiatric assistance, you should call 911, or go to the nearest emergency room. Both my email and voicemail are services yourself offered by an internet company. As such neither modality provides complete confidentiality. Hence I recommend that you use email and/or voice mail only for the purposes of scheduling/cancelling appointments. Consent to Treatment By signing below, I acknowledge that I have reviewed and avoid fully understand the complexities terms and conditions of this agreement. I have discussed such terms and conditions with Xxxxxxxx Xxxxxxxxx and have had any questions with regard to its terms and conditions answered to my satisfaction. I agree to abide by the terms and conditions of this agreement and consent to participate in the therapeutic process. Moreover, I agree to hold Xxxxxxxx Xxxxxxxxx free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that are described abovemay result from such treatment. Please note: Insurance rarely covers forensic psychology services.Client Name (please print) Client Signature Date

Insurance Reimbursement. In order for us to set realistic treatment goals Insurance is a contract between you and priorities, it is important to evaluate what resources are available to pay for your treatment. If you have a health benefits policy, it will usually provide some coverage for mental health treatment. You are responsible for any portion of the fees not covered by your insurance company. The general process is as follows: You pay your copay at time of session, your services We are submitted to your insurance company, and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for paymentparty to this contract. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursed. It is We will bill your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember that we try to work with primary insurance companies company as a courtesy to you. We will follow up on claims for services rejected by Although we may estimate what your insurance company only three timesmay pay, it is the insurance company that makes the final determination of your eligibility. After three rejectionsYou agree to pay any portion of the charges not covered by insurance. Once again, it is important to understand that you will be are responsible for full payment in full. At that time, we will provide you with a superbill if you choose to continue to pursue reimbursement by of your account (not your insurance company). In many instancesIt is very important that you find out exactly what mental health services your insurance policy covers. Also, we are able to look up if your eligibility and benefits on websites provided by the insurance companies. Howeverrequires a pre-authorization, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing your obtaining it. Due to the rising costs of health care, insurance policy statements and Explanation of Benefitsbenefits have increasingly become more complex. You should carefully read the section in your insurance coverage booklet that describes It is sometimes difficult to determine exactly how much mental health servicescoverage is available. If you have questions, you should call your plan and inquire. The number for this inquiry is usually noted on the back of your insurance card at the bottom. Of course, we will provide you with whatever information we can, based on our experience and will be happy to try to assist you in deciphering the information you receive from your carrier. “Managed health care Health Care” plans such as HMOs and PPOs sometimes often require advance authorization before they will provide reimbursement for mental health services. These plans are often oriented towards a limited to short-term treatment approach, approaches designed to resolve work out specific problems that are interfering interfere with onea person’s usual level of functioning. It may be necessary to seek additional approval for more therapy after a certain number of sessions. In our experience, while quite a lot While much can be accomplished in short short- term therapy, many some patients feel that they need more services are necessary after insurance benefits expireend. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that your contract with your health insurance agreements may require you company requires that we provide it with information relevant to authorize us the services that are provided to you. We are required to provide a clinical diagnosis, and sometimes . Sometimes we are required to provide additional clinical information such as a treatment plan plans or summarysummaries, or in rare casescopies of your entire Clinical Record. In such situations, a copy of we will make every effort to release only the entire recordminimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files, files and will probably be stored in a computer. Though all probability, some of it will be computerized. All insurance companies claim to keep such information confidential, but once it is in their hands, we have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information data bankdatabank. We will provide you with a copy of any report we submit if you request it. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits they run out before you feel ready to end our your sessions. It is important to remember that you always have the right to pay for my our services yourself and to avoid the complexities that are problems described above. Please note: Insurance rarely covers forensic psychology servicesabove unless prohibited by contract.

Insurance Reimbursement. In order for us It is the patient’s responsibility to set realistic treatment goals verify my membership as a provider on his/her insurance plan, to know the expected amount of co-pay and prioritiesdeductible such plan requires to be met, it is important and to evaluate obtain a pre-authorization of services before the initial session, if required. Knowing what resources are available to pay for your treatment. If you have a health benefits policy, it will usually provide some coverage for policy requires and what mental health treatment. You are responsible for any portion services will be covered is of the fees not covered by your insurance company. The general process is as follows: You pay your copay at time of session, your services are submitted to your insurance company, and you are then billed by BATT for any costs not covered by your insurance company. Please remember that insurance is considered a method of reimbursing the patient for the fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. Testing services are not always reimbursed. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Please remember that we try to work with insurance companies as a courtesy great value to you. We will follow up on claims for services rejected by your insurance company only three times. After three rejections, you will be responsible for payment in full. At that time, we will provide you with a superbill if you choose You may want to continue to pursue reimbursement by your insurance company. In many instances, we are able to look up your eligibility and benefits on websites provided by the insurance companies. However, the insurance companies clearly state that the information on the website is not a contractual agreement and that the information is subject to change without notice. Therefore, while we can give you a good idea of eligibility and benefits, we cannot be held accountable for differences between what we quote to you as your eligibility and benefits (based on the website information) and what the insurance companies actually pay on your behalf. YOU are responsible for reviewing your insurance policy statements and Explanation of Benefits. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questionsquestions about your coverage, you should please call your plan administrator. If you have a health insurance policy for which I am a provider, my staff will file your insurance for you and inquirehelp you receive the benefits to which you are entitled. The You will be asked to pay your portion of the fee at each session. You will be billed for co-pays, deductibles, non-covered services and services deemed not medically necessary (i.e. un-kept appointments, testing, phone consultations, school consultation, conjoint sessions, family without patient sessions) as your claims are adjudicated. Tri-Care Members: You will be given paperwork to file your own claims. Since I am not a Tri-Care provider, I do not recognize assignments or discounts which reduce the patient’s share of the cost. As a Tri-Care patient, you will be expected to pay the full amount of the fee. Verification of insurance benefits does not guarantee payment for services. Payment depends on a number of factors including the beneficiary’s eligibility, benefit plan limitations and the coordination of benefits with other plans. Benefits under Managed Care insurance companies often must be pre-certified and deemed medically necessary by the clinical case manager. If my services are not considered medically necessary, you will be billed for these services (see paragraph one at top of this inquiry is usually noted on page) At the back time of your initial session, you will be asked to bring your insurance card to verify your enrollment. If you do not present this card at the bottom. Of courseyour initial session, we your insurance will provide not be filed and you with whatever information we can, based on our experience and will be happy expected to try pay the full fee. Your insurance will be filed when our office is given this information. Initial: _____ Date: _______ INFORMED CONSENT The purpose for therapy is for treatment only and not for making custody recommendations. As a clinician, it is my role to assist you provide treatment, and not to make recommendations to courts in deciphering domestic matters. It would be a dual relationship for me to provide clinical services to a family member and then to conduct a custody evaluation by making recommendations to the information you receive from your carrierCourt. Managed health care plans such as HMOs and PPOs sometimes require advance authorization before they will provide reimbursement That would constitute a breach of professional ethics for mental health servicescounselors. These plans If you are often oriented towards involved in domestic litigation or become a short-term treatment approachparty to a divorce or custody action, designed you agree that you will not call me to resolve specific problems that are interfering with one’s usual level of functioningcourt to testify. It may be necessary to seek additional approval after a certain number of sessions. In our experience, while quite a lot can be accomplished in short term therapy, many patients feel that more services are necessary after insurance benefits expire. You should also be aware that insurance agreements may require you to authorize us 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, we Courts appoint professionals who have had no control over what they do with it. In some cases, they may share the information prior contact with a national medical information data bank. Once we have all of family to conduct custody evaluations and to make recommendations to the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits run out before you feel ready to end our sessionsCourt. It is important my policy not to remember testify in such cases, because experience has shown that the professional relationship is often harmed when counselors testify in divorce and custody cases. By signing this form, consenting to treatment, you always agree not to call me as a witness in domestic litigation. X ________ (Initial by client) AUTHORIZATION AND ACKNOWLEDGEMENT I do hereby seek and consent to participate in evaluation and /or treatment. I have read the right above information and understand the contents. I agree to pay for professional services as they are received. If insurance is filed on my services yourself behalf, I agree to be financially responsible for any service provided which my insurance company may deem not medically necessary. I authorize Xxxxx XxXxxxxxxx, Ph.D., to release any information requested by my insurance carrier for the purpose of processing claims. I agree not to call you as a witness in domestic litigation. I have received information regarding the notice of privacy practices which explains how this office will use and avoid disclose my health information of the complexities that are described above. Please note: Insurance rarely covers forensic psychology servicespurposes of my treatment, payment for my treatment, and health care operations.