FEE DISCLOSURE

Client Name *

First Name Last Name

Date of Birth *

Date

Accepted In-Network:

Buckeye (Cempatico)
Caresource Ohio
Cigna
Medicaid Ohio (ODHS)
Medical Mutual
Molina Marketplace (Medicaid)
OptumHealth Behavioral Solutions
Paramount
United Healthcare
United Healthcare Community Plan (Medicaid)

Self-Pay Options:

First appointment (60 minutes) $125

Psychotherapy (60 minutes) $90

Group Psychotherapy $50

Our WCAP Case Management team is available to assist clients with their Medicaid eligibility screening; if a client is eligible for Medicaid, a Case Manager will assist the client with their Medicaid application. Until Medicaid insurance is received, all clients will be responsible for the above our self-pay fee schedule for services.

Note: Medicaid eligibility is no guarantee of coverage

Cancellation Policy: I Understand that I need to give at least a 24-hour notice if I intend to cancel my appointment in order to avoid paying the cancellation fee $50.00. I understand that I have a right to terminate treatment at any time. I understand that I am financially responsible for paying for services that I have already received regardless of when services are terminated by either myself or the practitioner/agency. *

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Billing Authorization: I Understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance on the account for any professional services rendered. Payment is required at the time of service. I certify the information I have provided is true and correct to the best of my knowledge, and I will notify the agency of any changes in my health insurance, employment, or contact information as soon possible. *

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Credit/Debit Authorization: I authorize Whitehall CAP Inc. (WCAP Counseling) to securely store on file and charge my credit/debit card for receipt of services, any outstanding balances, or cancellation fees that may apply to my account. *

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Date *

Date

Name *

First Name Last Name

Signatureof Client/Guardian *

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