Please review this contract very carefuly as you will be held responsible to understand and comply with all expectations outlined in the following paragraphs.
IT IS OUR POLICY TO REQUIRE PAYMENT OF ALL SERVICES AT THE TIME THEY ARE RENDERED.THIS INCLUDES THE ENTIRE FEE FOR SERVICES UNTIL MENTAL HEALTH BENEFITS HAVE BEEN VERIFIED.Credit cards, health savings cards with the exception of American Express, and cash are acceptable forms of payment.***YOU ARE RESPONSIBLE FOR UNDERSTANDING YOUR MENTAL HEALTH BENEFIT WHICH CAN BE SEPERATE FROM YOUR MEDICAL BENEFIT. A SHORT LIST OF QUESTIONS IS INCLUDED IN THIS PACKET THAT WILL HELP YOU WHEN YOU CALL YOUR INSURANCE COMPANY TO CLARIFY YOUR BENEFIT. Doing this could potentially save unnecessary or unexpected costs, for which you will be held accountable.
Cancellation policy: YOU WIL BE BILLED FOR THE ENTIRE AMOUNT OF YOUR SESSION IF 24 HOURS ADVANCE NOTICE IS NOT GIVENTO CANCELING YOUR APPOINTMENT. THIS INCLUDES FIRST APPOINTMENTS. It is important to understand that insurances cannot be billed for missed appointments; therefore you are responsible for the entire cost of that session. We will have your credit card on file in a HIPPA compliant, secure program and charge accordingly.
Calls made requesting consultation on the phone for support for clincall issues outside of scheduled appointment times will be billed at a rate of $130.00 per hour, $70.00 per half hour, and $35.00 per 15 minutes.
Outstanding Payments: A finace of charge of 3% monthly (annual percentage rate of 36%) of the unpaid balance will be added monthly. Should collections become neccesary by legal suit or other means, the customer agress to pay all costs of the collection including attourney fees, court costs, including charges and collection agency fees which would be 35% of the balance assigned, with or without suit.
Assigment of Benefits:
I hereby assign all mental health benefits to which I am entitled including private insurance and any otherhealth plan to: Janna McGaw, LCSW. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignmet is to be considered as valid as an original. I understnd that I am financially responsible for all charges whether or not paid by said insurance.
Your therapist is required by law to keep your communications in the strictest confidence and cannot reveal any information shared with them to anyone without your explicit written cosent except 1)in the case of abuse or neglect of children or the elderly and 2)when a client is in imminent danger of harming themselves or others.
I agree to the terms and conditions of this contract.