Choices!® Financial Policy
The Person Responsible for Payment of Account is required to sign this form as agreement to the Payment Contract for Services, which explains the fees and collection policies of the clinic, and this Financial Policy. Your insurance policy, if any, is a contract between you and the insurance company; the clinic is not part of the contract with you and your insurance company.
If you are referred to Choices for services by a third party that is responsible for payment, you are still required to sign the Financial Policy and the Payment Contract for Services. This is necessary so that in the event you become ineligible for services with that payor source, or if you choose to participate in services above and beyond those authorized by that payor source, you understand that you will be responsible for payment.
As a courtesy to you, the clinic will bill insurance companies and other third-party payers, but can not guarantee such benefits or the amounts covered, and is not responsible for the collection of such payments or for the timely billing of sessions. In some cases insurance companies or other third-party payers may consider certain services as not reasonable or necessary or may determine that services are not covered. In such cases the Person Responsible for Payment of Account is responsible for payment of services should the insurance company not pay Choices for any reason. Clients are responsible for payments regardless of any insurance company’s arbitrary determination of usual and customary rates. I have disclosed and provided all insurance coverage information that may be applicable and I understand that I am responsible for all the costs associated with the non-disclosure of any applicable insurance coverage.
The Person Responsible for Payment (as noted in the Payment Contract for Services) will be financially responsible for payment of such services. The Person Responsible for Payment of Account is financially responsible for paying all fees not paid by insurance companies or third-party payers after 60 days. All past due balances are assessed a 1½ % per month (18% per year) finance charge after 60 days. Payments not received after 90 days will accrue a $10 late fee per month and are subject to collections. Should an account be taken to collection, you will be financially responsible for all collection fees and legal fees that the clinic incurs through the process utilized to collect the outstanding delinquent balance, in an addition to a $50 handling/processing fee. Should an account be taken to Small Claims Court for collection, you will be financially responsible for the legal costs for filing the case, costs for attorneys, office time spent on the case, all other costs that the clinic incurs through the process utilized to collect the outstanding delinquent balance, and an additional $50 handling/processing fee. Payment in full of any past due balance is expected prior to being seen by the clinic for future services and/or for obtaining copies of records. I understand that there is a copy and processing charge for records.
Insurance deductibles and co-payments are due at the time of service. Although it is possible that mental health coverage deductible amounts may have been met elsewhere, this amount will be collected by the clinic until the deductible payment is verified to the clinic by the insurance company or third-party provider through their Explanation of Benefits (EOB) form.
All insurance benefits will be assigned to this clinic (by insurance company or third-party provider) unless the Person Responsible for Payment of Account pays the entire balance each session.
Clients are responsible for payments at the time of services. The adult accompanying a minor (or guardian of the minor) is responsible for payments for the minor at the time of service. Unaccompanied minors will be denied non-emergency service unless charges have been pre-authorized.
Missed appointments or cancellations with less than 24 hours notice prior to the appointment are charged a rate noted in the Payment Contract for Services.
Payment methods include check, cash, money order or VISA / Mastercard. $27.50 will be charged for returned checks. Clients using charge cards may either use their card at each session or sign a document allowing the clinic to automatically submit charges to the charge card after each session.
The clinic is not responsible for lost, stolen, or damaged personal property. The undersigned understands and agrees that the clinic is not responsible for, nor shall be held liable for, any accident or personal injury to themselves, their minor children, or other persons in their charge at all clinic locations, or as a result of any service provided by the clinic.
Questions regarding the financial policies can be answered by the Office Manager.
I authorize Choices! Counseling Services to disclose case records (diagnoses, case notes, psychological reports, testing results, or other requested material) to the previously listed third-party payer or insurance company for the purpose of receiving payment reimbursement directly to Choices! Counseling Services.
Choices!® Consent for Treatment
I understand that I am giving informed consent to treatment. Choices! Assessment and Treatment process was created to provide services for clients on an outpatient basis. The creation of all outpatient services have been designed to help and promote the client's success in daily functioning, minimize dysfunction or harm to self and/or others, and if necessary refer to appropriate services and/or agencies. As part of the assessment and treatment process, I may be asked to participate in informational and educational programs, group or individual counseling, or referred to agencies outside of Choices' system.
I do consent to participate in mental health services rendered by Choices! I also understand that I will currently see the assigned clinician on the mutually agreed upon premises for outpatient clinical services. Additionally, I understand that payment for all services is to be rendered at the completion of each session unless other arrangements have been established with the Office Staff.
I understand that after therapy begins, I have the right to withdraw my consent to therapy at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with the therapist before ending therapy. I understand that no promises have been made to me by this agency about the results of treatment, the effectiveness of the procedures used, or the number of sessions necessary for therapy to be effective.
I have read the issues, policies, statements, stipulations, and points contained herein. I have had the opportunties to have my questions, if any, fully answered. I agree to act according to the points covered in this document. I hereby agree to enter into therapy with this agency (or to have the client enter therapy), and to cooperate fully and to the best of my ability, as shown by my agreement below.