Thank you for choosing The Bridges Core Services Agency for your medical needs. We are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our Client Financial policies.
Client Financial Responsibilities
· The Client is ultimately responsible for the payment for treatment and care.
· We will bill your insurance for you. However, the Client is required to provide the most correct and updated information regarding insurance. If we are unable to process payment through your insurance for any reason we will bill you for the services provided at the following rates:
1. Individual Psychotherapy
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1-hour Session
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$ 55.00
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2. Group Psychotherapy
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1-hour Session
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$ 75.00
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3. Family Psychotherapy
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1-hour Session
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$ 75.00
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4. Diagnostic Evaluation
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Flat fee
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$ 50.00
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5. Diagnostic Evaluation with Medical
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Flat fee
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$250.00
|
6. Community Psychiatric Supportive Treatment
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1-hour Session
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$ 35.00
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7. Therapeutic Behavioral Services
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1-hour Session
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$ 35.00
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8. Psychosocial Rehabilitation
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1-hour Session
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$ 35.00
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9. Substance Use Disorder Assessment & ASAM
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Flat fee
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$ 50.00
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10. Substance Use Disorder Services
|
1-hour Session
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$ 35.00
|
11. Intensive Outpatient Treatment
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Hourly Rate
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$ 75.00
|
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Clients are responsible for payment of copays, coinsurance, deductibles and all other procedures or treatment not covered by their insurance plan
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Copays are due at the time of service
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Coinsurance deductibles and non-covered items are due 30 days from receipt of billing
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Clients may incur, and are responsible for payment of additional charges, if applicable. These charges may include: Charge for returned checks - $30.00
By my signature below, I hereby authorize assignment of financial benefits directly to The Bridges Core Services Agency and any associated healthcare entities for service rendered as allowed under standard third-party contracts. I understand that I am financially responsible for charges not covered by this assignment.
Client Acknowledgement and Authorization
We respect Client confidentiality and only release personal health information about you in accordance with the State and Federal law. The attached notice describes our policies related to the use of the records of your care and how you may get access to this information. Please review this policy carefully. By my signature below, I acknowledge that I have received and read the privacy notice provided by The Bridges Core Services Agency to release medical and other information acquired in the course of my examination and/or treatment to the necessary insurance companies, third party payors, and or other physicians or healthcare entities to participate in my care.