D. Cooksy, L.C.S.W., P.A.
8504 Six Forks Road Suite 201
Raleigh, NC 27615
BUSINESS POLICY AND PATIENT AGREEMENT
This agreement contains information about my professional services and business policies. In order to receive the professional services offered by D. Cooksy, L.C.S.W., P.A., carefully read, sign, and date the last page. I will be happy to discuss any questions that you may have.
SCHEDULE OF FEES
Fees are payable in full at each session. Please make checks payable to my corporate name, "D. Cooksy, L.C.S.W., P.A.". Refer to www.cooksypa.com for electronic payment options and ACH details.
First Diagnostic Interview 140.00
Therapy sessions per 45-minute session 110.00
Sessions longer than 45 minutes 12.00
will be charged in 5-minute increments
Telephone Consultations longer than 5 minutes, 25.00
per quarter hour or any portion thereof
Any additional consultation or other services 110.00
performed on behalf of the client, per hour
Completion of any forms, 15-minute increments 25.00
Payment for service is due at the end of each session – this would include any additional outstanding balance for services (telephone consultation; requested letters; etc.) since the previous session. Services may be interrupted until payment is made. Finance charges are added when payment is not made by the 31st day after the date of service. A late charge of $12.00 is added for every month of unpaid balances.
Final payment is expected on behalf of the client before reports are released. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure payment. This may involve hiring a collection agency or going through small claims courts which will require me to disclose your name, address, phone number, and the amount due. If legal action is necessary, the cost will be included in the claim.
In separated or divorced families, the person who initiates services with D. Cooksy, L.C.S.W., P.A. is held financially responsible. I do not bill another person or an estranged spouse unless that individual informs us in writing of his or her willingness to pay for services rendered.
Any Legal Related Services requires a $1,800.00 payment in advance and is nonrefundable.
LATE CANCELLATIONS OR MISSED APPOINTMENTS
If unable to keep an appointment, kindly give 24 hours notice by leaving a text, email, or voice message at (919) 413-6639. Respective to listed fees, charges will be made for time reserved.
HEALTH INSURANCE POLICY
Services provided by D. Cooksy, L.C.S.W., P.A. office are covered under many health insurance policies. However, most insurance companies reimburse mental health services at a different rate from other medical services and or may not cover services at all. Most policies have annual deductibles and may set limits in dollars or the number of sessions allowed per year. Since benefit language varies, it is wise to review your own policy carefully for coverage and any limitations. Blue Cross/Blue Shield (excluding plans that ‘outsource’ mental health) claims are filed through D. Cooksy, L.C.S.W., P.A. All other insurances are out of network. You will receive payment verification that includes the information required to process payment. If your insurance plan is not accepted per above, you will be required to file. In the event that insurance coverage changes, it is the responsibility of the patient to notify D. Cooksy, L.C.S.W., P.A. and to accept financial responsibility for services denied due to the change.
D. Cooksy, L.C.S.W., P.A. will consult with professional specialists when clinically advisable. If for some reason unavailable, it is important that professional colleagues have access to relevant information in order to provide the best possible care for your family. The confidentiality of the work that I do together with you as a client is upheld at all times. However, there are certain exceptions to this rule:
1) suspect child abuse or if there is reasonable cause to believe a disabled adult
is in need of protective services, then appropriate authorities are contacted.
2) clear and imminent danger to self or another person
3) need for health oversight, then certain entities have the power when necessary to
subpoena relevant records should D. Cooksy, L.C.S.W., P.A. be the focus of an
4) if there are legal proceedings, patient/therapist communications are privileged
except for the following:
* If mental status is an issue before the court
* If the judge authorizes a court order because he or she feels that communication
is necessary to the proper administration of justice
* If a government agency is requesting information for health oversight activities, I
may be required to provide it for them
* If a complaint or lawsuit is lodged, D. Cooksy, L.C.S.W., P.A. may
disclose relevant information regarding that patient in order to defend the practice.
* If a patient files a worker’s compensation claim, I am required by law to provide
mental health information to your employer and the NC Industrial Commission.
HEALTH INSURANCE PORTABILITY ACT
The Health Insurance Portability Act (HIPPA) and the Notice of Privacy Practices, is a federal law that provides you additional privacy protection and explains your rights with regard to the release of any Protected Health
Information (PHI). The law requires that D. Cooksy, L.C.S.W., P.A.
obtain your signature acknowledging that you may read or have a copy of my Privacy Practices Agreement.
READ CAREFULLY AND COMPLETE
I have read, understand, and accept the policies described above.
I understand that I am financially responsible for services rendered and that my account is due in full each at the end of each session. I understand that D. Cooksy, L.C.S.W., P.A. does not accept assignments of benefits from insurance carriers other than those listed above.
I also understand that a late charge of $12.00 per month will accrue on any unpaid portion of my account and that there is a $25.00 service charge for any returned checks. I understand that during the course of therapy fees may be increased. Fees will be reviewed periodically and will be increased no more than once during any calendar year.
I understand it is my responsibility to secure authorization from my insurance company, PPO, or Managed Health Care Company before any office visits occur. I also understand that the therapist must release minimally necessary Protected Health Information to insurance companies should they request it. Psychotherapy notes are not released.
* I agree to pay the amount due each visit in full.
* I understand and accept the confidentiality policy.
As a patient of D. Cooksy, L.C.S.W., P.A., I acknowledge the opportunity to review the HIPPA Notice of Privacy Practices. I understand that if requested I may have a copy to keep.