Common use of Insurance Reimbursement Clause in Contracts

Insurance Reimbursement. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will facilitate your receipt of the benefits to which you are entitled including filling out forms and speaking with insurance representatives. You will be held responsible for full payment of our agreed upon fee should your insurance company deny benefits or should your coverage lapse. Therefore, it is very important that you find out exactly what mental health benefits your insurance policy covers. Read your plan carefully and call your service representative if you have questions. Many insurance plans require advance authorization before they will provide reimbursement for mental health services. These plans often are oriented toward a short-term model and provide only a certain amount of sessions per year. Many insurance companies may only authorize a few sessions at a time and I will need to periodically call them to authorize additional sessions. When I call to authorize treatment or continue our sessions, I will provide them with the minimum amount of information needed, usually including a diagnosis, goals for treatment, and a brief summary of your current functioning. It is possible, but very rare, that they would require a copy of my clinical record. This information will become part of insurance company files and is likely to be computerized. All insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with it. In some cases, they may share the information with a national medical information data bank. By signing this Agreement, you agree that I can provide requested information to your insurance carrier. If you request it, I will provide you with a copy of any report that I am asked to submit. I make it my policy to inform you along the way of where we stand with your insurance company and what kind of information they have requested. Should insurance coverage end for some reason, we can discuss an out-of-pocket session fee. You can always choose to select this option and have the right to pay for my services yourself to avoid the complexities of the insurance industry.

Insurance Reimbursement. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will facilitate your receipt of fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled including filling out forms and speaking with entitled; however, you (not your insurance representatives. You will be held company) are responsible for full payment of our agreed upon fee should your insurance company deny benefits or should your coverage lapsemy fees. Therefore, it It is very important that you find out exactly what mental health benefits services your insurance policy covers. Read your plan carefully and call your service representative if you have questions. Many insurance plans require advance authorization before they will provide reimbursement for mental health services. These plans often are oriented toward a short-term model and provide only a certain amount of sessions per year. Many insurance companies may only authorize a few sessions at a time and I will need to periodically call them to authorize additional sessions. When I call to authorize treatment or continue our sessionsIf necessary, I will ask you to fill out an authorization so that I can provide them with information to your insurance company that will allow me to provide the minimum amount of information needed, usually including a diagnosis, goals necessary to secure payment for treatment, and a brief summary of your current functioningthe services I provide for you. It is possibleThis authorization will be in effect for one year, but very rarecan be revoked at any time. However, if revoked, I will continue to have the right to forward information necessary to process claims for services already provided. You should also be aware that they would require your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a copy clinical diagnosis and brief substantiation of my that diagnosis. Sometimes I am required to provide additional clinical recordinformation. This information is limited to the date of treatment and brief description of the services provided, including the type of therapy provided. This information will become part of the insurance company files and is likely to will probably be computerizedstored in a computer. All Though all insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information data bankdatabank. By signing this Agreement, you agree that I can provide requested information to your insurance carrier. If you request it, I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I am asked 1 can provide requested information to submityour carrier. I make it my policy to inform you along Once we have all of the way of where we stand with information about your insurance company coverage, we will discuss what we can expect to accomplish with the benefits that are available and what kind of information will happen if they have requestedrun out before you feel ready to end your sessions. Should insurance coverage end for some reason, we can discuss an out-of-pocket session fee. You can It is important to remember that you always choose to select this option and have the right to pay for my services yourself to avoid the complexities of the insurance industrypotential problems described above.

Insurance Reimbursement. If you have a health insurance policy, it will usually provide some to full coverage for mental health treatmenta Psychological Evaluation. I We will facilitate your receipt of fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled including filling out forms and speaking with entitled; however, you (not your insurance representatives. You will be held company) are responsible for full payment of our agreed upon fee should your insurance company deny benefits or should your coverage lapsefees. Therefore, it It is very important that you we find out exactly what mental health benefits services your insurance policy covers. Read You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about coverage, call your plan carefully administrator. We will provide you with whatever information we can based on our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, we will be willing to call the company on your service representative if you behalf. Due to the rising costs of health care, insurance benefits have questionsincreasingly become more complex. Many insurance It is sometimes difficult to determine exactly how much mental health coverage is available. Managed health care plans such as HMO’s and PPO’s often require advance authorization before they will provide reimbursement for mental health services. These plans are often are oriented toward a short-term model and limit coverage for psychological evaluations. Some clients feel that they need more services after insurance bene­fits end. Some managed care plans will not allow me to provide only a certain amount of sessions per yearservices to you once your benefits end. Many If this is the case, we will do our best to find another provider who will help you continue your needs. You should also be aware that most insurance companies may only authorize a few sessions at a time and I will need to periodically call them require you to authorize additional sessions. When I call me to authorize treatment or continue our sessions, I will provide them with a clinical diagnosis. Sometimes we have to provide additional clinical information such as treatment plans or summaries, or copies of the minimum amount of information needed, usually including a diagnosis, goals for treatment, and a brief summary of your current functioning. It is possible, but very rare, that they would require a copy of my clinical recordentire record (in rare cases). This information infor­mation will become part of the insurance company files and is likely to will proba­bly be computerizedstored in a computer. All Though all insurance companies claim to keep such information confidential, but once it is in their hands, I we have no control over what they do with itit once it is in their hands. In some cases, they may share the information infor­mation with a national medical information data bankdatabank. By signing this Agreement, you agree that I can provide requested information to your insurance carrier. If you request it, I We will provide you with a copy of any report that I am asked to submitwe submit if you request it. I make it my policy to inform you along Once we have all of the way of where we stand with information about your insurance company and what kind of information they have requested. Should insurance coverage end for some reasoncoverage, we will discuss what we can discuss an out-of-pocket session feeexpect to accomplish with the benefits that are available. You can It is important to remember that you always choose to select this option and have the right to pay for my our services yourself to avoid the complexities of the insurance industryproblems described above [unless prohibited by contract].

Insurance Reimbursement. If you have a health insurance policy, it will usually provide some coverage for plan to use out-of-network mental health treatment. coverage, I will facilitate your receipt of fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled including filling out forms and speaking with entitled; however, you (not your insurance representatives. You will be held company) are responsible for full payment of our agreed upon fee should your insurance company deny benefits or should your coverage lapsemy fees. Therefore, it It is very important that you find out exactly what mental health benefits services your insurance policy covers. Read You should also be aware that your plan carefully and call contract with your service representative if you have questionshealth insurance company requires that I provide it with information relevant to the services that I provide to you. Many insurance Maryland permits me to send some information without your consent in order to file appropriate claims. I am required to provide them with a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans require advance authorization before they will provide reimbursement for mental health servicesor summaries, or copies of your entire Clinical Record. These plans often are oriented toward a short-term model and provide only a certain amount of sessions per year. Many insurance companies may only authorize a few sessions at a time and I will need to periodically call them to authorize additional sessions. When I call to authorize treatment or continue our sessionsIn such situations, I will provide them with make every effort to release only the minimum information about you that is necessary for the purpose requested. Maryland law prevents insurers from making unreasonable demands for information, but there are no specific guidelines about what unreasonable includes. If I believe that your health insurance company is requesting an unreasonable amount of information neededinformation, usually including a diagnosis, goals for treatment, I will call it to your attention and a brief summary of your current functioningwe can discuss what to do. It is possibleYou can instruct me not to send requested information, but very rarethis could result in claims not being paid and an additional financial burden being placed on you. Once the insurance company has this information, that they would require a copy of my clinical record. This information it will become part of the insurance company files and is likely to will probably be computerizedstored in a computer. All Though all insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with 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 insurance carrier. If carrier if you request it, I will provide you with a copy of any report that I am asked to submit. I make it my policy to inform you along the way of where we stand with your insurance company and what kind of information they have requested. Should insurance coverage end for some reason, we can discuss an out-of-pocket session fee. You can always choose to select this option and have the right to pay for my services yourself to avoid the complexities of the insurance industryseek reimbursement.

Insurance Reimbursement. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will facilitate your receipt of fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled including filling out forms and speaking with entitled; however, you (not your insurance representatives. You will be held company) are responsible for full payment of our agreed upon fee should your insurance company deny benefits or should your coverage lapsemy fees. Therefore, it It is very important that you find out exactly what mental health benefits your services you insurance policy covers. Read your plan carefully and call your service representative if you have questions. Many insurance plans require advance authorization before they will provide reimbursement for mental health services. These plans often are oriented toward a short-term model and provide only a certain amount of sessions per year. Many You should be aware that most insurance companies may only authorize a few sessions at a time and I will need require you to periodically call them authorized me to authorize additional sessions. When I call to authorize treatment or continue our sessions, I will provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the minimum amount of information needed, usually including a diagnosis, goals for treatment, and a brief summary of your current functioning. It is possible, but very rare, that they would require a copy of my clinical recordentire record (in rare cases). This information will become part of the insurance company files and is likely to will probably be computerizedstored in a computer. All Though all insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information data bankdatabank. By signing this Agreement, you agree that I can provide requested information to your insurance carrier. If you request it, I will provide you with a copy of any report that I am asked to submitsubmit if you request it. I make it my policy to inform you along Once we have all of the way of where we stand with information about your insurance company coverage, we will discuss what we can expect to accomplish with the benefits that are available and what kind of information will happen if they have requestedrun out before you feel ready to end our sessions. Should insurance coverage end for some reason, we can discuss an out-of-pocket session fee. You can It is important to remember that you always choose to select this option and have the right to pay for my services yourself to avoid problems described above (with exceptions for some insurers). Your signature below indicates that you have read the complexities of the insurance industry.information in this document and agree to abide by its terms during our professional relationship. Signature: (parent/guardian) Name (printed): (parent/guardian) Signature: (parent/guardian) Name (printed): (parent/guardian) Signature: (child) Name (printed): (child) Date:

Insurance Reimbursement. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will facilitate your receipt of the benefits to which you are entitled including filling out forms and speaking with insurance representatives. You will be held responsible for full payment of our agreed upon fee should your insurance company deny benefits or should your coverage lapse. Therefore, it is very important that you find out exactly what mental health benefits your insurance policy covers. Read your plan carefully and call your service representative if you have questions. Many insurance plans require advance authorization before they will provide reimbursement for mental health services. These plans often are oriented toward a short-term model and provide only a certain amount of sessions per year. Many insurance companies may only authorize a few sessions at a time and I will need to periodically call them to authorize additional sessions. When I call to authorize treatment or continue our sessions, I will provide them with the minimum amount of information needed, usually including a diagnosis, goals for treatment, and a brief summary of your current functioning. It is possible, but very rare, that they would require a copy of my clinical record. This information will become part of insurance company files and is likely to be computerized. All insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with it. In some cases, they may share the information with a national medical information data bank. By signing this Agreement, you agree that I can provide requested information to your insurance carrier. If you request it, I will provide you with a copy of any report that I am asked to submit. I make it my policy to inform you along the way of where we stand with your insurance company and what kind of information they have requested. Should insurance coverage end for some reason, we can discuss an out-of-pocket session fee. You can always choose to select this option and have the right to pay for my services yourself to avoid the complexities of the insurance industry. Contacting Me I am only in the office on specific days. Since this is the case, I am often not immediately available by telephone. To reach me, call (000) 000-0000. Leave a message in my confidential voicemail. Leave your name, phone number, and how I can reach you. I usually check my voice mail 1-2 times per day during the business week. I will make every effort to return your call the same day or early the following business day. If we have difficulty reaching each other, please leave times when I can reach you and alternative phone numbers. If you are experiencing a clinical emergency call me directly. If I am available, I will call you back as soon as possible. If you are in crisis and cannot reach me or wait for me to return your call, you should call your family physician, psychiatrist, or Crisis Services at 834-3131 or Spectrum Cares at 882-4357 (a 24-hour crisis hot-line with counselors that can insure your safety or talk to you about the crisis). If I know that I will be out of town for an extended period of time, I will have another counselor designated to be on-call for me in crisis situations. If you feel that you might potentially utilize these crises options, please let me know during our session so that we can develop a comprehensive crisis plan. Professional Records Both law and the standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in situations where you are a danger to yourself (or others) or where others have supplied information to me confidentially, you may examine and/or receive a copy of your Clinical Record. This request must be made in writing. Because they are professional records, they can be misinterpreted or upsetting to lay readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. If you would like me to copy your records for you, I will charge a copying fee of 75 cents per page. Patient Rights Please see attached New York Notice Form for a listing of your rights. Minors & Parents New York law gives children of any age the right to independently consent to and receive mental health treatment without parental consent if they request it and if it is determined that such services are necessary and requiring parental consent would have a detrimental effect on the course of the child’s treatment. Even where parental consent is given, children over the age of 12 have a right to control access to their treatment records. If you are age 13 or older, I will request an agreement from your parents that they consent to allow me to maintain your confidentiality. If they agree, I will provide them only with general information about our work together unless I feel that there is a high risk that you will seriously harm yourself, harm another, or are in an abusive situation. In these situations, I will notify them of my concerns about your safety. If they request it, I will provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you (if possible), and will do the best I can to resolve any objections you may have about what I am prepared to discuss with your parents.

Insurance Reimbursement. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will facilitate your receipt of fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled including filling out forms and speaking with entitled; however, you (not your insurance representatives. You will be held company) are responsible for full payment of our agreed upon fee should your insurance company deny benefits or should your coverage lapse. Thereforemy fees, it It is very important that you find out exactly what mental health benefits services your insurance policy covers. Read your plan carefully and call your service representative if you have questions. Many insurance plans require advance authorization before they will provide reimbursement for mental health services. These plans often are oriented toward a short-term model and provide only a certain amount of sessions per year. Many You should also be aware that insurance companies may only authorize a few sessions at a time and I will need to periodically call them require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional sessionsclinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). When I call to authorize treatment or continue our sessionsBe aware that you may have authorized this release of information from your insurance company when you signed up for benefits from them. In such situations, I will provide them with make every effort to release only the minimum amount of information needed, usually including a diagnosis, goals about you that is necessary for treatment, and a brief summary of your current functioning. It is possible, but very rare, that they would require a copy of my clinical recordthe purpose requested. This information will become part of the insurance company files and is likely to be computerizedfile. All Though all insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information data bank. 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 insurance carrier. If you request it, I will provide you with a copy Once we have all of any report that I am asked to submit. I make it my policy to inform you along the way of where we stand with information about your insurance company coverage, we will discuss what we can expect to accomplish with the benefits available and what kind of information will happen if they have requestedrun out before you feel ready to end our sessions. Should insurance coverage end for some reason, we can discuss an out-of-pocket session fee. You can It is important to remember that you always choose to select this option and have the right to pay for my services yourself to avoid the complexities problems described above, unless prohibited by contract. Contacting Me: I am often not immediately available by telephone. While I am usually in my office between 9 a.m. and 5:00 p.m. during the week, I will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by an voicemail that I monitor frequently. If you are unable to reach me and feel that you can’t wait for me to return you call, contact Siskiyou County Mental Health at 800-842-8979 or 911. You may also go to any emergency room for help. If I will be unavailable for an extended time, I will provide you with the name of the insurance industrya colleague to contact, if necessary.

Insurance Reimbursement. If Quo Vadis Therapy Center does not submit billing to insurance companies. However, some insurance providers may cover your therapy at Quo Vadis depending on your policy's coverage of out-of-network providers. Contact your insurance carrier to learn more about what services your policy covers. Even if your insurance policy does cover services I provide, you have a health will still be expected to pay my fees according to the process described above. I can provide you with an invoice for the services you receive from me, which you might use to receive reimbursement from your insurance policy, it will usually provide some coverage for mental health treatmentprovider. I will facilitate not reimburse you for any difference between what you pay in fees to me and what your receipt of the benefits insurance provider may or may not reimburse to which you are entitled including filling out forms and speaking with insurance representativesyou. You will should also be held responsible for full payment of our agreed upon fee should aware that your contract with your health insurance company deny benefits may require that I provide it with information relevant to the services that I provide to you. I would likely be required to provide a clinical diagnosis. I may also be required to provide additional clinical information such as treatment plans or should summaries, or copies of your coverage lapseentire clinical record. Therefore, it is very important that you find out exactly what mental health benefits your insurance policy covers. Read your plan carefully and call your service representative if you have questions. Many insurance plans require advance authorization before they will provide reimbursement for mental health services. These plans often are oriented toward a short-term model and provide only a certain amount of sessions per year. Many insurance companies may only authorize a few sessions at a time and I will need to periodically call them to authorize additional sessions. When I call to authorize treatment or continue our sessionsIn such situations, I will provide them with make every effort to release only the minimum amount of information needed, usually including a diagnosis, goals about you that is necessary for treatment, and a brief summary of your current functioning. It is possible, but very rare, that they would require a copy of my clinical recordthe purpose requested. This information will become part of the insurance company files and is likely to will probably be computerizedstored in a computer. All Though all insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information data bankdatabank. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above [unless prohibited by contract]. 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 health information to your insurance carrier. If you request it, I will provide you with a copy of any report that I am asked to submit. I make it my policy to inform you along the way of where we stand with your insurance company and what kind of information they have requested. Should insurance coverage end for some reason, we can discuss an out-of-pocket session fee. You can always choose to select this option and have the right to pay for my services yourself to avoid the complexities of the insurance industryprovider.

Insurance Reimbursement. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will facilitate your receipt of the benefits to which you are entitled including filling out forms and speaking with insurance representatives. You will be held responsible for full payment of our agreed upon fee should your insurance company deny benefits or should your coverage lapse. Therefore, it is very important that you find out exactly what mental health benefits your insurance policy covers. Read your plan carefully and call your service representative if you have questions. Many insurance plans require advance authorization before they will provide reimbursement for mental health services. These plans often are oriented toward a short-term model and provide only a certain amount of sessions per year. Many insurance companies may only authorize a few sessions at a time and I will need to periodically call them to authorize additional sessions. When I call to authorize treatment or continue our sessions, I will provide them with the minimum amount of information needed, usually including a diagnosis, goals for treatment, and a brief summary of your current functioning. It is possible, but very rare, that they would require a copy of my clinical record. This information will become part of insurance company files and is likely to be computerized. All insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with it. In some cases, they may share the information with a national medical information data bank. By signing this Agreement, you agree that I can provide requested information to your insurance carrier. If you request it, I will provide you with a copy of any report that I am asked to submit. I make it my policy to inform you along the way of where we stand with your insurance company and what kind of information they have requested. Should insurance coverage end for some reason, we can discuss an out-of-pocket session fee. You can always choose to select this option and have the right to pay for my services yourself to avoid the complexities of the insurance industry. Contacting Me I am often not immediately available by telephone. To reach me, call (000) 000-0000. Leave a message in my confidential voicemail. Leave your name, phone number, and how I can reach you. Remove any call blocking devices until I return the call. I usually check my voice mail 1-2 times per day during the business week. I will make every effort to return your call the same day or the following business day. If we have difficulty reaching each other, please leave times when I can reach you and alternative phone numbers. You may send an email at xxxxxxxx@xxxxxxxxxxxxxxxxxxxx.xxx. If you are experiencing a clinical emergency or crisis and cannot reach me or wait for me to return your call, you should call your family physician, psychiatrist, or Crisis Services at 251-7575 (a 24-hour crisis hot-line with counselors that can insure your safety or talk to you about the crisis) or 911.

Insurance Reimbursement. If In order for us to set realistic treatment goals and priorities, It is I important to evaluate the resources you have a health insurance policy, it will usually provide some coverage available to pay for mental health your treatment. I will facilitate your receipt of the benefits to which you are entitled including filling out forms am a “fee for service” provider and speaking with therefore am not on any insurance representatives. You will be held responsible for full payment of our agreed upon fee should your insurance company deny benefits or should your coverage lapsepanel. Therefore, it is very important that you find out exactly what “out of network” mental health benefits services your insurance policy covers. Read You should carefully read the section in your plan carefully and call your service representative if you have questions. Many insurance plans require advance authorization before they will provide reimbursement for coverage booklet that describes mental health services. These plans often are oriented toward a short-term model and provide only a certain amount of sessions per yearIf you have questions about the coverage, call your plan administrator. Many insurance companies may only authorize a few sessions at a time and I will need to periodically call them to authorize additional sessions. When I call to authorize treatment or continue our sessionsOf course, I will provide them you with whatever information I can based on my experience and will be happy to help you in understanding the minimum amount information you receive from your insurance company. If you choose to submit for reimbursement, I will provide you with an invoice that has the information you well need to complete the forms for your insurance company. Please be aware that most insurance companies require your clinical diagnosis be included on any reimbursement form. Sometimes your insurance company request I submit additional clinical information, such as treatment plans, progress notes or summaries, or copies of information needed, usually including a diagnosis, goals for treatment, and a brief summary of your current functioning. It is possible, but very rare, that they would require a copy of my clinical recordthe entire record (in rare cases). This information will become part xxx of the insurance company files and is likely to be computerizedfiles. All Although all insurance companies claim to keep such information confidential, but I have not control over what they do with it once it is in their hands, I have no control over what they do with it. In some cases, they may share the information with a national medical information data bankdatabank. By signing this Agreement, you agree that I can provide requested information to your insurance carrier. If you request it, I will provide you with a copy of any report records I submit if you request it. You understand that, by using your insurance, you authorize me to release such information to your insurance company. I will t ry to keep that information limited to the minimum necessary. It is important to remember that paying for services yourself, without the use of insurance, avoids the problems described above SERtfICE DELItfERY Modalities of services delivered are on based treatment goals developed from the diagnostic process. In general there are several principles that underlay the approach to treatment. I am often not available immediately by telephone. Though I am usually in the office between 9am and 9pm, I won’t answer the phone when I am with a patient. When I am unavailable, my telephone is answered by voicemail that I am asked to submitmonitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact if necessary LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by state law and/or HIPAA. But, there are some situations where I am permitted or required to disclose information without either your consent or Authorization: □ I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my policy patient. The other professionals are also legally bound to inform keep the information confidential. Ordinarily, I will not tell you along about these consultations unless I believe that it is important to our work together. □ If I believe a patient is threatening serous bodily harm to another, I am required to take protective actions. These actions may include notifying the way potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm himself/herself, I may be obligated to seek for him/her or to contact family members or others who can help provide protection. In a similar situation occurs on the course of where we stand our work together, I will attempt to fully discuss it with your insurance company and what kind of information they have requestedbefore taking any action. Should insurance coverage end for some reason□ In most legal proceedings, we can discuss an out-of-pocket session fee. You can always choose to select this option and you have the right to pay for prevent me from providing any information about your treatment In some legal proceedings a judge may order my services yourself testimony if he/she determines that the issues demand it, and I must comply with the court order. □ If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to avoid defend myself. □ If a patient uses health insurance HMO/PPO/EAP/MCO, disclosure of confidential information may be required by your health insurance carrier in order to process the complexities claims. I will provide only the minimum necessary information. I have no control or knowledge over what insurance companies do with information that is submitted. You must be aware that submitting a mental health invoice of reimbursement carries a certain amount of risk of confidentiality, privacy or future capacity to obtain health or life insurance. □ If I observe or have knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if an elder or dependent adult credibly reports that he or she has experienced behavior including an act or omission constituting physical abuse, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, the insurance industrylaw requires that I report to the appropriate government agency. Once such a report is filed, I be may be required to provide additional information.

Insurance Reimbursement. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will facilitate your receipt of the benefits to which you are entitled including filling out forms and speaking with insurance representatives. You will be held responsible for full payment of our agreed upon fee should your insurance company deny benefits or should your coverage lapse. Therefore, it It is very important that you find out exactly what mental health benefits services your insurance policy covers. Read You should carefully read the section in your plan carefully and call your service representative if you have questions. Many insurance plans require advance authorization before they will provide reimbursement for coverage booklet that describes mental health services. These plans often are oriented toward If you have questions about the coverage, call your plan administrator. Of course, Caring Hearts Professional Counseling Services, LLC will provide you with whatever information we can base on our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, Caring Hearts Professional Counseling Services, LLC will be willing to call the company on your behalf. While a lot can be accomplished in short-term model therapy, some patients feel that they need more services after insurance benefits end. SoonerCare and other managed care agencies will not allow me to provide only a certain amount of sessions per yearservices to you once your benefits end. Many If this is the case, we will do our best to aid in finding another provider who will help you continue your psychotherapy. You should also be aware that most insurance companies may only authorize a few sessions at a time and I will need to periodically call them require you to authorize additional sessions. When I call Caring Hearts Professional Counseling Services, LLC to authorize treatment or continue our sessions, I will provide them with a clinical diagnosis. Often, agencies are required to provide additional clinical information such as treatment plans or summaries, or copies of the minimum amount of information needed, usually including a diagnosis, goals for treatment, and a brief summary of your current functioning. It is possible, but very rare, that they would require a copy of my clinical recordentire record (in rare cases). This information will become part of the insurance company files and is likely to will probably be computerizedstored in a computer. All Though all insurance companies claim to keep such information confidential, but once it is in their handsCaring Hearts Professional Counseling Services, I have LLC has 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. By signing this Agreement, you agree that I can provide requested information to your insurance carrier. If you request it, I We will provide you with a copy of any report that I am asked to submitsubmitted, if you request it. I make it my policy to inform you along Once we have all the way of where we stand with information about your insurance company coverage, we will discuss what we can expect to accomplish with the benefits that are available and what kind of information will happen if they have requestedrun out before you feel ready to end our sessions. Should insurance coverage end for some reason, we can discuss an out-of-pocket session fee. You can It is important to remember that you always choose to select this option and have the right to pay for my services yourself to avoid the complexities of the insurance industryproblems described above [unless prohibited by contract].

Insurance Reimbursement. If you have a health insurance policy, it we will usually fill out forms and provide some coverage for mental health treatment. I will facilitate your receipt of you with whatever assistance we can in helping you receive the benefits to which you are entitled including filling out forms and speaking with entitled; however, you (not your insurance representatives. You will be held company) are responsible for full payment of our agreed upon fee should your insurance company deny benefits or should your coverage lapsefees. Therefore, it It is very important that you find out exactly what mental health benefits services your insurance policy covers. Read You should also be aware that your plan carefully contract with your health insurance company with references to all inclusions and call exclusions applied to your service representative if you have questionspolicy. Many insurance plans require advance authorization before they We will provide reimbursement for mental health servicesyou with information relevant to the services that we provide to you. These We are required to provide a clinical diagnosis. Sometimes we are required to provide additional clinical information such as treatment plans often are oriented toward a short-term model and provide or summaries, or copies of your entire Clinical Record. In such situations, we will make every effort to release only a certain amount of sessions per year. Many insurance companies may only authorize a few sessions at a time and I will need to periodically call them to authorize additional sessions. When I call to authorize treatment or continue our sessions, I will provide them with the minimum amount of information needed, usually including a diagnosis, goals about you that is necessary for treatment, and a brief summary of your current functioning. It is possible, but very rare, that they would require a copy of my clinical recordthe purpose requested. This information will become part of the insurance company files and is likely to will probably be computerizedstored in a computer. All Though all insurance companies claim to keep such information confidential, but once it is in their hands, I 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 I can provide requested information to your insurance carrier. If Your signature below indicates that you request ithave read the information in this document and agree to abide by its terms during our professional relationship. Signed: Date PATIENT CONSENT FORM: I understand that under the HIPAA act of 1996, I have certain rights of privacy regarding my protected health information. I understand that this information can and will provide be used to: conduct, plan and direct my treatment and follow-up among multiple healthcare providers who may be involved in that treatment directly or indirectly; obtain payment from third party; conduct normal healthcare operations such as quality assessments and Physician and Physician certifications. I have been informed by you of the above notices of privacy practices. I have been given the right to review this notice prior to signing this consent. I understand that this organization has the right to change its NOTICE OF PRIVACY PRACTICES from time to time and that I may contact this organization at any time at the address noted below to obtain a copy. I understand that I may request in writing that you restrict how my private my privacy information is used or disclosed to carry out treatment, payment, or health care operation. I also understand this organization is not required to agree with my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. Patient name: Signature: Relationship to patient: Date: I, , in realize that any account not paid within thirty (30) days could be subject to a copy Bill Process Fee of any report $1.00 per month and/or an interest of 12% per annum. I realize that I am asked to submit. I make it my policy to inform you along financially liable for these fees unless disputed with the way of where we stand with your insurance company and what kind of information they have requested. Should insurance coverage end for some reasonprovider or their billing agency, we can discuss an out-of-pocket session fee. You can always choose to select this option and have the right to pay for my services yourself to avoid the complexities of the insurance industry.Atlas Billing, Inc.

Insurance Reimbursement. If you have a health insurance policy, it will usually provide some coverage for plan to use an out-of-network mental health treatment. coverage, I will facilitate your receipt of fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled including filling out forms and speaking with entitled; however, you (not your insurance representatives. You will be held company) are responsible for full payment of our agreed upon fee should your insurance company deny benefits or should your coverage lapsemy fees. Therefore, it It is very important that you find out exactly what mental health benefits services your insurance policy covers. Read You should also be aware that your plan carefully and call contract with your service representative if you have questionshealth insurance company requires that I provide it with information relevant to the services that I provide to you. Many insurance Maryland/D.C. law permits me to send some information without your consent in order to file appropriate claims. I am required to provide them with a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans require advance authorization before they will provide reimbursement for mental health servicesor summaries, or copies of your entire clinical record. These plans often are oriented toward a short-term model and provide only a certain amount of sessions per year. Many insurance companies may only authorize a few sessions at a time and I will need to periodically call them to authorize additional sessions. When I call to authorize treatment or continue our sessionsIn such situations, I will provide them with make every effort to release only the minimum information about you that is necessary for the purpose requested. Maryland/D.C. law prevents insurers from making unreasonable demands for information, but there are no specific guidelines about what unreasonable includes. If I believe that your health insurance company is requesting an unreasonable amount of information neededinformation, usually including a diagnosis, goals for treatment, I will call it to your attention and a brief summary of your current functioningwe can discuss what to do. It is possibleYou can instruct me not to send requested information, but very rarethis could result in claims not being paid and an additional financial burden being placed on you. Once the insurance company has this information, that they would require a copy of my clinical record. This information it will become part of the insurance company files and is likely to will probably be computerizedstored on a computer. All Though all insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with 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 Agreementagreement, you agree that I can provide requested information to your insurance carrier. If carriers if you request it, I will provide you with a copy of any report that I am asked chose to submit. I make it my policy to inform you along the way of where we stand with your insurance company and what kind of information they have requested. Should insurance coverage end for some reason, we can discuss an out-of-pocket session fee. You can always choose to select this option and have the right to pay for my services yourself to avoid the complexities of the insurance industryseek reimbursement.

Insurance Reimbursement. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will facilitate You, not your receipt of the benefits to which you insurance company, are entitled including filling out forms and speaking with insurance representatives. You will be held responsible for full payment of our agreed upon fee should your insurance company deny benefits or should your coverage lapsemy fees. Therefore, it It is very important that you find out exactly what mental health benefits services your insurance policy covers. Read your plan carefully , including (a) whether there is a preferred provider list you must choose from and call your service representative if whether I’m listed as a preferred provider, (b) whether you have questions. Many insurance plans require advance need pre-authorization before they will provide reimbursement for mental health services. These plans often any services are oriented toward a shortprovided, (c) your co-term model pay amount, (d) any deductibles, and provide only a certain amount (e) any maximum limit to the number of sessions per year. Many Once we have all the information about your insurance companies may only authorize coverage, we can discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end treatment. Your contract with your health insurance company requires that I provide them with information relevant to the services that I provide to you. I am required to provide a few sessions at a time and clinical diagnosis. Sometimes I will need am required to periodically call them to authorize provide additional sessionsclinical information such as treatment plans or summaries, or copies of your entire clinical record. When I call to authorize treatment or continue our sessionsIn such situations, I will provide them with make every effort to release only the minimum amount of information needed, usually including a diagnosis, goals about you that is necessary for treatment, and a brief summary of your current functioning. It is possible, but very rare, that they would require a copy of my clinical recordthe purpose requested. This information will become part of the insurance company files and is likely to will probably be computerizedstored in a computer. All insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with itthis information once it is in the insurance company’s 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 insurance carrier. If you request it, I will provide you with a copy of any report that I am asked to submit. I make it my policy to inform you along the way of where we stand with your insurance company and what kind of information they have requested. Should insurance coverage end for some reason, we can discuss an out-of-pocket session fee. You can always choose to select this option and have the right to pay for my services yourself to avoid the complexities of the insurance industry.

Insurance Reimbursement. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will facilitate your receipt of the benefits to which you are entitled including filling out forms and speaking with insurance representatives. You will be held responsible for full payment of our agreed upon fee should your insurance company deny benefits or should your coverage lapse. Therefore, it is very important that you find out exactly what mental health benefits your insurance policy covers. Read your plan carefully and call your service representative if you have questions. Many insurance plans require advance authorization before they will provide reimbursement for mental health services. These plans often are oriented toward a short-term model and provide only a certain amount of sessions per year. Many insurance companies may only authorize a few sessions at a time and I will need to periodically call them to authorize additional sessions. When I call to authorize treatment or continue our sessions, I will provide them with the minimum amount of information needed, usually including a diagnosis, goals for treatment, and a brief summary of your current functioning. It is possible, but very rare, that they would require a copy of my clinical record. This information will become part of insurance company files and is likely to be computerized. All insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with it. In some cases, they may share the information with a national medical information data bank. By signing this Agreement, you agree that I can provide requested information to your insurance carrier. If you request it, I will provide you with a copy of any report that I am asked to submit. I make it my policy to inform you along the way of where we stand with your insurance company and what kind of information they have requested. Should insurance coverage end for some reason, we can discuss an out-of-pocket session fee. You can always choose to select this option and have the right to pay for my services yourself to avoid the complexities of the insurance industry. Contacting Me I am only in the office on specific days. Since this is the case, I am often not immediately available by telephone. To reach me, call (000) 000-0000. Leave a message in my confidential voicemail. Leave your name, phone number, and how I can reach you. I usually check my voice mail 1-2 times per day during the business week. I will make every effort to return your call the same day or early the following business day. If we have difficulty reaching each other, please leave times when I can reach you and alternative phone numbers. Please be aware that I am NOT able to receive text messages. If you are experiencing a clinical emergency call me directly. If I am available, I will call you back as soon as possible. If you are in crisis and cannot reach me or wait for me to return your call, you should call your family physician, psychiatrist, or Crisis Services at 834-3131 or Spectrum Cares at 882-4357 (a 24-hour crisis hot-line with counselors that can insure your safety or talk to you about the crisis). If I know that I will be out of town for an extended period of time, I will have another counselor designated to be on-call for me in crisis situations. If you feel that you might potentially utilize these crises options, please let me know during our session so that we can develop a comprehensive crisis plan. Professional Records Both law and the standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in situations where you are a danger to yourself (or others) or where others have supplied information to me confidentially, you may examine and/or receive a copy of your Clinical Record. This request must be made in writing. Because they are professional records, they can be misinterpreted or upsetting to lay readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. If you would like me to copy your records for you, I will charge a copying fee of 75 cents per page. Patient Rights Please see attached New York Notice Form for a listing of your rights. Minors & Parents New York law gives children of any age the right to independently consent to and receive mental health treatment without parental consent if they request it and if it is determined that such services are necessary and requiring parental consent would have a detrimental effect on the course of the child’s treatment. Even where parental consent is given, children over the age of 12 have a right to control access to their treatment records. If you are age 13 or older, I will request an agreement from your parents that they consent to allow me to maintain your confidentiality. If they agree, I will provide them only with general information about our work together unless I feel that there is a high risk that you will seriously harm yourself, harm another, or are in an abusive situation. In these situations, I will notify them of my concerns about your safety. If they request it, I will provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you (if possible), and will do the best I can to resolve any objections you may have about what I am prepared to discuss with your parents.

Insurance Reimbursement. If I am an in-network provider for your insurance company, we will make arrangements for me to file your insurance for you. At each visit, you have a will be responsible for your copayment and any deductible based on the reimbursement rates quoted by the insurance company. If the insurance company allows less than expected, the difference will be added to your monthly statement. If the insurance company allows more than expected, the overpayment will be applied to future copayments or refunded to you, depending upon your preference. You should also be aware that your contract with your health insurance policycompany requires that I provide it with a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, it will usually provide some coverage for mental health treatmentdevelopmental history, medical history, family history, chemical use history, or even copies of your entire Clinical Record. I will facilitate your receipt of the benefits to which you are entitled including filling out forms and speaking with insurance representatives. You will be held responsible for full payment of our agreed upon fee should your insurance company deny benefits or should your coverage lapse. Therefore, it is very important that you find out exactly what mental health benefits your insurance policy covers. Read your plan carefully and call your service representative if you have questions. Many insurance plans require advance authorization before they will provide reimbursement for mental health services. These plans often are oriented toward a short-term model and provide only a certain amount of sessions per year. Many insurance companies may only authorize a few sessions at a time and I will need to periodically call them to authorize additional sessions. When I call to authorize treatment or continue our sessionsIn such situations, I will provide them with let you know that the information has been requested, and make every effort to release only the minimum amount of information needed, usually including a diagnosis, goals about you that is necessary for treatment, and a brief summary of your current functioning. It is possible, but very rare, that they would require a copy of my clinical recordthe purpose requested. This information will become part of the insurance company files and is likely to will probably be computerizedstored in a computer. All Though all insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with 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 insurance carrier. If you request itI am not an in-network provider for your insurance company, I will provide you with a copy of any report that statement regarding services rendered, fill out forms, and provide you with whatever assistance I am asked can in helping you receive the benefits to submit. I make it which you are entitled; however, you will be responsible for paying my policy to inform you along the way of where we stand with fee at each session and obtaining reimbursement from your insurance company. It is important to remember that in either case, you (not your insurance company) are ultimately responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers, as well as verify with the insurance company the amount of benefits available, annual deductibles, and what kind copayment fees. Of course, I will provide you with whatever information I can based on my experience. Due to the rising costs of information they health care, insurance benefits have requestedincreasingly become more complex. Should insurance It is sometimes difficult to determine exactly how much mental health coverage end for some reason, we can discuss an out-of-pocket session feeis available. You can It is important to remember that you always choose to select this option and have the right to pay for my services yourself to avoid the complexities problems described above. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call by the end of the next worked business day for routine calls, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room (ask for the psychiatrist on call), or LifeLine (000) 000-0000 or (000) 000-0000 for TTY services. Also, if you live outside of Monroe County (000) 000-0000. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in a Clinical Record. It includes information about your reasons for seeking testing and or therapy, a description of the ways in which your problem impacts on your life, interview notes, a test report, 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 industrycarrier. Except in unusual circumstances that involve danger to yourself and others, you may examine and/or receive a copy of your Clinical Record if you request it in writing. You should be aware that pursuant to New York law, psychological test data are not part of a patient’s record. 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 licensed mental health professional with training in test interpretation so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of $0.25 per page (and for certain other expenses). The exceptions to this policy are contained in the Notice Form. If I refuse your request for access to your Clinical Record, you have a right of review, which I will discuss with you upon your request. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS, AND THAT YOU HAVE BEEN INFORMED OF AND UNDERSTAND THE LIMITS ON PATIENT CONFIDENTIALITY; IT ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE BEEN ADVISED OF HOW TO REVIEW THE HIPAA NOTICE FORM IF YOU WISH. Client’s Signature (or Parent/Guardian Signature) Date Authorizations to Release Information: Insurance: I hereby give authorization to release any information necessary including, but not limited to, diagnosis, treatment plan, treatment summary, developmental history, medical history, chemical use history, and family history, to my insurance company and/or to the insurance company’s managed care plan to satisfy mental health and/or medical insurance claims and treatment reviews.

Insurance Reimbursement. If you have a I am not an “in-network” provider for any insurance plans. I am considered an “out-of-network” provider. Most health insurance policy, it will usually policies provide some coverage for out-of-network providers for mental health treatment. I will facilitate your receipt of the benefits It is useful for you to which you are entitled including filling out forms and speaking with insurance representatives. You will be held responsible for full payment of our agreed upon fee should your insurance company deny benefits or should your coverage lapse. Therefore, it is very important that you find out exactly what mental health benefits services your insurance policy coverscovers (e.g. number of sessions, deductible, percentage paid once the deductible is met). Read In some cases you might be misinformed by your insurance company so it is useful to write down the person with whom you spoke and the time and date. If you have questions about the coverage, call your plan carefully and call administrator. If you would like to submit claims to your service representative if you have questions. Many insurance plans require advance authorization before they will provide reimbursement for mental health services. These plans often are oriented toward a short-term model and provide only a certain amount of sessions per year. Many insurance companies may only authorize a few sessions at a time and company I will need be happy to periodically call them send you a receipt. Payment is expected at the time of service. If insurance pays Xx. Xxxx, you will receive a credit to authorize additional your account. Once we know how much your insurance is going to pay Xx. Xxxx, you can pay only the balance that is not expected to be covered. Initial here . Your contract with your health insurance company requires PHI for billing. This is limited to your clinical diagnosis and dates of service needed to bill for sessions. When I call to authorize In rare cases insurance requests clinical information such as treatment plans or continue our sessions, I summaries. This will provide them with the minimum amount of information needed, usually including a diagnosis, goals for treatment, and a brief summary of only happen at your current functioning. It is possible, but very rare, that they would require a copy of my clinical recordrequest. This information will become part of the insurance company files and is likely to be computerizedoften stored in a computer. All Though all insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information data bank. By signing this Agreement, you agree that I can provide requested information to your insurance carrier. If you request it, I will provide you with a copy of any report you ask me to submit, if you request it. By signing the attached Information Sheet you agree to the office policies listed above, and also agree that I am asked can provide requested information-detailed in the above paragraph-to submit. I make it my policy to inform you along the way of where we stand with your insurance company and what kind of information they have requested. Should insurance coverage end for some reason, we can discuss an out-of-pocket session fee. You can always choose to select this option and have the right to pay for my services yourself to avoid the complexities of the insurance industrycarrier.

Insurance Reimbursement. If you have a health insurance policy, it will usually may provide some coverage for mental health treatment. I will facilitate your receipt of fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled including filling out forms and speaking with entitled; however, you (not your insurance representatives. You will be held company) are responsible for full payment of our agreed upon fee should your insurance company deny benefits or should your coverage lapsemy fees. Therefore, it It is very important that you find out exactly what mental health benefits services your insurance policy covers. Read covers from your plan carefully administrator. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and call your service representative if you have questions. Many insurance plans PPOs may require advance authorization before they will provide reimbursement for mental health services. These plans often are oriented toward a sometimes limited to short-term model and provide only treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain amount number of sessions per year. Many insurance companies may only authorize a few sessions at a time and I will need to periodically call them to authorize additional sessions. When You should also be aware that filing a claim with your health insurance company requires that I call provide it with information relevant to authorize the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or continue our sessionssummaries, or copies of your entire Clinical Record. In such situations, I will provide them with make every effort to release only the minimum amount of information needed, usually including a diagnosis, goals about you that is necessary for treatment, and a brief summary of your current functioning. It is possible, but very rare, that they would require a copy of my clinical recordthe purpose requested. This information will become part of the insurance company files and is likely to will probably be computerizedstored in a computer. All Though all insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with itit once it is in their hands. In some cases, they may share the information with a national medical information data bankdatabank or your employer. By signing this Agreement, you agree that I can provide requested Once we have all of the information to about your insurance carrier. If you request itcoverage, I we will provide you discuss what we can expect to accomplish with a copy of any report the benefits that I am asked to submit. I make it my policy to inform you along the way of where we stand with your insurance company are available and what kind of information will happen if they have requestedrun out before you feel ready to end your sessions. Should insurance coverage end for some reason, we can discuss an out-of-pocket session fee. You can It is important to remember that you always choose to select this option and have the right to pay for my services yourself to avoid the complexities of the insurance industryproblems described above.