Financial Agreement for Psychiatric Treatment Between Stress Management & Mental Health Clinics and Its Clients
Charges: The rate of $392 is charged for the initial assessment, and $205 is the standard and customary fee for your provider per each therapeutic session. Additional fees for services beyond the usual session may result in additional charges which would be discussed with you in advance. It is important to note that if the provider is under contract with an insurance company, Health Maintenance Organization, managed care contract, or Employee Assistance Program agreement, the charges will be in compliance with that contract. The rates are based on a standard 45 minute assessment session and 15-30 minute medication checks after the assessment, including the time necessary for discussion of treatment goals, medication side effects, etc. which will be regularly reviewed along with the risks and benefits of treatment choices.
Client’s responsibilities: The client is responsible for all charges, including any charges that their insurance coverage contract allows for and any out of pocket fees including deductibles and co-pays that are spelled out in your insurance contract. All deductibles, co-pay, or other required charge is due at the time of each appointment. It is the client’s responsibility to understand the terms of their insurance contract. If you do not know your coverage or understand your coverage it is your responsibility to contact your insurance carrier directly. It is critical to immediately inform the Stress Management & Mental Health Clinic office of any changes to insurance coverage, residence, employer, or type of coverage. Failure to inform the office of these changes could result in the client being responsible for the full standard and customary charges for any sessions that are not covered because of this lapse in information. Remember that the client is fully financially responsible and the clinic only bills insurance, or others, as a convenience to the client. Your treatment contract with Stress Management and Mental Health Clinics, Inc, precedes the beginning of any therapeutic relationship or treatment. It also precedes the agreement with your insurance carrier, or other payor relationship including any contract between the psychotherapist and managed care companies, EAP’s etc.
Cancellation Policy: In order that professional services are utilized in the most productive levels, and in order that services can be promptly provided to those in need, it is Stress Management & Mental Health Clinic’s policy to require a 24 hour advance notice of cancellations of any appointment. If the cancellation is not made in compliance with this policy, the client assumes financial responsibility for the cost of the missed appointment. This charge is $100 for each standard therapy session. These charges will be billed directly to the client and is not eligible for insurance reimbursement, due at the time of the next appointment.
Request for Records: Any requests for records (or partial records) to be transferred to any location/source (including the client themselves) for any reason will require an advance payment of $15.00, which is in compliance with Wisconsin State Laws. Records will be sent only after receiving payment. Any record greater than ten (10) pages will require an additional $0.25 per page that is requested to be sent. A signed release of information, in compliance with Wisconsin State Law is required prior to the release of records.
Other Charges: Telephone conversations with providers that last longer than 5 minutes will be billed at $2.00 per minute thereafter. This is a standard clinic policy and is not reimbursable from insurance carriers. By signing this document, you are agreeing to this policy. Any additional services requested by any client for any reason will be billed as a separate charge and must be paid prior to the next clinical session. The rate for this provider is $392 per hour for sending a letter, treatment summary, etc. to courts, attorneys, state agencies, probation officers, etc. and for all service time not covered by insurance. This will be charged under all circumstances.
Statement of Agreement:
I have read and understand the statement of policy and financial responsibilities and I agree to them. Any exceptions or variations will be discussed with my therapist and Stress Management & Mental Health Clinics, Inc. and will have a written agreement, by both parties, of any changes with any part of this contract.