CONSENT TO TREATMENT
The undersigned, client/client’s legal guardian, voluntarily consent to outpatient treatment for mental health, co-occurring, and/or substance use and authorize Mindfully to provide such outpatient treatment that is determined to be medically necessary or otherwise appropriate. These services may include individual or group counseling/therapy, Diagnostic Assessment, and Psychological Testing.
MEDICARE PAYMENT
I, the undersigned, certify that any information given by me in applying for payment under Title XVII of the Social Security Act is complete, accurate, and current. As a Medicare Beneficiary, the clietn has the right to receive Medicare covered services. I acknowledge that I have the right to be involved in any decisions about my treatment and services and who will pay for them.
WAIVER OF LIABILITY FOR NON-APPROVED SERVICES
Ohio law requires Mindfully to inform the undersigned that if your insurance company did not give prior approval for therapy services and you choose to have services provided, you would be required to pay for the services. My signature acknowledges I have read and understand the above. If my insurance company denies payment, I agree to be personally and fully responsible for the payment of all services incurred. These services include both formal and informal letters, appearances in court, reports, and extended phone calls.
EXPLANATION OF SERVICES
· Our clinicians typically see clients Monday through Saturday, although sometimes Sunday appointments are available.We share this suite with our colleagues and we provide ongoing supervision for each other.
· We provide Individual, Family, Couples and Group Counseling and are happy to discuss these options with you.
· If a crisis occurs when we are not in the office you may call our main number (513) 939-0300 and you will be directed as to how we may be reached.
· Your therapist cannot engage in multiple relationships with you. This means the therapist can only have one role in a family, the therapist cannot be the individual therapist for family members or siblings unless the therapy is "family therapy" or "couples counseling". In the case that there are multiple persons involved in the treatment, only one will be the primary client and all documentation is kept under that client name (as well as billing is done under one client). This means that not everyone present would have the same access to the chart. Your therapist can explain this to you/your family. Furthermore, no multiple relationships means that your therapist cannot purchase items from you or be in any other relationship with you (spiritually, financially, emotionally, familial, political, administrative, legal, through social media, etc).
· We make the assumption that you can change and grow, and that some of this change can occur within a relatively short period of time. We strive to do brief and effective treatment.
· Our fee is $160 for the initial session for an LPCC/LISW and 140 per hour for a regular 45-55 minute session, $125 for the initial session for an LSW/LPC and $100 per hour for a regular 45-55 minute session and $75 per session for a regular 30 minute session and $300 for the initial session for an MD
· Payment is expected at the time of service. You are responsible for the charges. If you are paying through your insurance, you are responsible for your co-pay or deductible at time of service and for any amount left unpaid by your insurance. We can provide you with an estimate of what you will owe per service. It is your responsibility to call your insurance to verify.
· Additional fees will be charged for letters, appearances in court, reports and extended phone calls. These things are not covered by insurance. Your therapist will discuss any additional fee with you before it is charged. These additional fees can include phone calls between you and your child's therapist if the child is a minor. Payment is required prior to any letters being released or calls made on your behalf at your request to third parties. Written consent for these services involving third parties will be required prior to the contact as well via a release of information
· We view the therapeutic relationship as a partnership that is principally dedicated to your growth and to finding solutions. Part of our job is to remind you of your own strengths and abilities while you go about the business of creating more of the type of life that you want.
· As with nearly any type of treatment, there is the chance that it may not be helpful. The “fit” between client and therapist is important to good treatment outcome. In the beginning of treatment, you may feel worse before you feel better. Therefore, we want to hear from you throughout our work together about how we are doing – so that we can make any needed adjustments to help you more effectively. it is your right to transfer therapists if you feel your therapist is not a good fit. Please call and let us know, we are happy to assist in this process
· Information discussed within the therapy setting is held confidential and will not be shared without written permission except under limited situations which under reasonable circumstances would be discussed with you before disclosure is made. These situations include revelations of unreported child or elder abuse, imminent suicide or harm to others, or reports of exploitation by a therapist.
· Our practice is only to release clinical notes generated from your contact with us. We do not release raw materials or records obtained from third parties
· If you believe your rights have been violated, you have a right to discuss your concerns with our clinical director by calling our office and requesting the call, filing a complaint with the Ohio Counselor, Social Worker, and Marriage and Family Therapist Board, transfer to a different therapist within Compass Point and/or terminate services at Compass Point.
LATE CANCELLATIONS, MISSED APPOINTMENTS
I understand that I am required to provide at least 24 hours notice if I (or the client named below) are unable to keep a scheduled appointment. In the event that I do not provide 24 hours advance notice, I acknowledge that Mindfully has the right to charge me for the scheduled appointment.
Returned Check Fee: Mindfully charges a fee for any check returned by my financial institution, regardless of reason. In such event, I agree to pay Mindfully the returned check fee of up to $50.oo.
Delinquent Account: I understand that Mindfully may turn my account over to a collection agency if I do not pay on a timely basis. Mindfully has a separate collection policy, which will be provided to me if I ask for it. I also understand that if my account is sent to a collection agency a 35-50% surcharge will be applied to the balance by the collection agency.
ANCILLARY SERVICES
These are any extra services not covered by your insurance.
· Letter or Report writing- $150 per hour prorated. Payment is required prior to writing letter.
· Telephonic Services- $150 per hour prorated. Coaching calls will not apply
· Court Related Charges-Your therapist will not go to court voluntarily. Please understand that when your therapist goes to court other clients have to have their appointments canceled for the week. The Magistrate or Judge hearing your case must subpoena the therapist.
o The office must receive a retainer cost of $500.00 prior to therapist blocking out their schedule to appear in court.
o $150 per hour from portal to portal
o Any additional charges over that will be billed to you following the hearing.
o In the event the therapist believes that testifying in court would be detrimental to the therapy process the therapist may hire their own attorney to have the subpoena overruled. Any legal fees resulting from this action will be charged to the client that has requested the therapist’s appearance.
· Testing- Prices for testing vary and are available upon request.
· Medical Record request: Prices are based on Ohio regulations and are subject to change
CLIENT FINANCIAL RESPONSIBILITY AGREEMENT
In consideration of services received or to be received, the undersigned requests that payment of authorized insurance benefits, including Medicare, if the client is a Medicare beneficiary, be made on the client’s behalf to Mindfully for any services provided to the client. It is my responsibility to notify Mindfully of any changes in my health care coverage. In some cases exact insurance benefits cannot be determined by Mindfully and/or my mental health care insurer if the submitted claims or any part of them are denied for payment. The undersigned acknowledges that by signing this form I am accepting financial responsibility as explained above for all payment for services received. I acknowledge that I am financially responsible for all charges associated with mental health services provided by Mindfully to the client named below. I understand that payment for services is due at the time services are rendered unless special arrangements are made in advance.
I authorize release of any information concerning the client's health care, advice and treatment provided for the purpose of evaluation and administering claims for insurance and/or employee assistance program benefits. I also hereby authorize payment of insurance and/or employee assistance program benefits otherwise payable to me directly to Mindfully.
AUTOMATIC BILLING OR PAY AT TIME OF SERVICE
Accounts with Mindfully may enroll to automatically have account balances billed to your credit card. If you wish to take advantage of this service please complete the lines below. By providing your billing information you acknowledge consent for us to automatically process charges to the credit card you have provided below.
We will only charge services rendered to your card. Your card will NOT be charged in the event that you are assessed a charge for canceling within 24 hours of an appointment or for not keeping a scheduled appointment. However, we do ask that you pay these charges in a timely manner.
I understand that I have given Mindfully permission to charge my credit card. I also understand that if my insurance applies any amount to my deductible or denies payment, the full amount of the visit will be billed to my credit card.