FEE DISCLOSURE

FEE DISCLOSURE

CANCELLATION /BILLING POLICY
Client Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Accepted In-Network:

Anthem
Blue Cross Blue Shield
Buckeye (Cempatico)
Caresource Ohio
Cigna
Humana
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 to follow 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. *
initial
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. *
initial
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 *

Month Day Year
Date
Name *

First Name Last Name
Signatureof Client/Guardian *

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