The Growth Center for Counseling and Wellness 4925 Charlestown Rd NA, IN 47150
Your fee for service is payable before each session. Payment can be made using cash, personal check, Visa, Master Card, AMEX or Discover. Upon request you can receive an invoice as a receipt for your session. For clients filing insurance a co-pay is due before each session. Deductibles are also charged when due. A copy of your insurance card is required along with all necessary preauthorization numbers required by your insurance carrier. You are expected to pay the full fee if insurance authorizations are not completed in advance prior to your services. You are responsible to inform the office of any change in your insurance coverage. You are also responsible for any fees for services that are not covered by your insurance. The Growth Center will file the insurance claims and receive payments by assignment. Your signature below gives permission for assignment of benefits to come to The Growth Center for insurance payments made for our clinical services. You hereby authorize the provider to release all information necessary to secure the payment of benefits to any billing agent for the provider, any insurance company and any referring physician. Your signature also acknowledges you have, or will, read and understand the HIPAA notice of privacy practices and patient’s rights and responsibilities document in the Intake Packet.
Your signature on this form will give the Growth Center permission to communicate with your referring professional, other healthcare professionals you see for services and your insurance carrier to verify your personal information. If your account becomes delinquent, it may be processed through an external collection agency and credit bureau. All returned checks will be subject to a $25 service charge. You are also accepting your provider’s participation in the Indiana PDMP Gateway if controlled substances are prescribed. This is required by Indiana law. Fees may change without advance notice.
This fee schedule is solely for informational purposes and subject to change:
- Psychiatric Evaluation: $650
- Psychiatric Medication Management: $150*, $250* or $350*
- Counseling Intake: $500
- Counseling follow-up sessions: $250
- Intern Counseling Fee: $50
Professional time outside the clinical services listed above will be billed at $500 per hour door to door including wait and travel time. Court appearances require a 3 hour minimum to be paid 3 business days prior to the court date. Court appearances outside Floyd County incur extra mileage charges.
DISABILITY or CUSTODY evaluations are NOT provided at the Growth Center. Photocopy charges will be billed at the rate for medical records established by Indiana law. For this reason fees are subject to change. If you need to delay your payment for a session, arrangements must be made in advance with the office manager. If you arrive late for your appointment we cannot guarantee an appointment.
Fees and balances are due at the time services are provided. A 24 hour notice is required to cancel a session. There is a $50 fee for all late cancellations and missed appointments. Missed appointments must be paid in full before further services can be provided. An active Credit Card must be retained on account during the time you are a client of The Growth Center to cover account balances. If your unpaid balance on your account is over $200 and we have completed processing of your insurance claims and a current balance is outstanding due to loss of insurance, rejected claims due to deductibles or ineligibility. Then a payment plan will be used to secure full payment for services provided. This plan will automatically be implemented as a condition of this financial agreement. A copy of this plan is available at the front desk.
The Growth Center does not accept Medicaid, Medicare or ACA Exchange plans.