Charges for TMS Therapy:
1. Transcranial Magnetic Stimulation (“TMS”) therapy is provided by TMS Medical of the Hudson Valley, P.C. d/b/a Clearwave Medical (“Clearwave”). The cost for TMS therapy may vary depending on the treatment protocol prescribed for you. Clearwave’s standard fee schedule is as follows:
Initial Motor Threshold: $950.00 per unit
TMS Treatment: $750.00 per unit
Repeat Motor Threshold: $900.00 per unit
2. The typical course of treatment is 36 sessions. Additional treatments may be required for maximum benefit.
Insurance Coverage for TMS Therapy:
1. Many insurers provide coverage for TMS therapy based on specific conditions and treatment protocols and often require prior authorization before beginning treatment. While our team can assist in obtaining prior authorization for treatment and can assist with obtaining an estimate for the out-of-pocket cost of coverage, it is ultimately your responsibility to verify insurance benefits and determine if you have coverage based on your diagnosis and particular benefit plan and how much treatment will cost you out of pocket. Please be aware that authorization only determines that the requested service is medically necessary and does not guarantee payment of benefits or that your insurance will pay the full amount of Clearwave’s charges. Payment is also subject to the terms of your health plan at the time services are delivered and benefit limitations and/or exclusions. Any estimates provided by Clearwave for your out-of-pocket costs are only provided as a courtesy and Clearwave cannot guarantee that the estimated out-of-pocket cost will be equal to amount you actually owe under your insurance plan. You are responsible for all Clearwave charges for your care.
2. To the extent Clearwave has reached an agreement with your insurance company regarding your treatment – either because Clearwave is in-network with your insurance company or because Clearwave has reached a separate agreement regarding your TMS treatment – you hereby authorize Clearwave to bill your insurance company for those services and for your insurance company to pay such sums directly to Clearwave. If your insurance company remits such payment to you directly, you shall redirect such payment to Clearwave as soon as possible.
3. For self-pay, out-of-network, and off-label care, payment is due in full at the time of the initial course of therapy. If your insurance carrier approves coverage of TMS therapy, we will collect any copayments, coinsurance and deductibles required under your insurance plan based on our actual charges. Please be aware that our charge to insurance may differ from our charge for self-pay patients and the amount your insurance company approves may differ from our actual charge. You are responsible for payment of our actual charge.
4. If coverage of TMS therapy is denied and you would like to appeal the denial, your insurance carrier may require a letter of medical necessity. We will provide you with a letter upon request.
1. In order for TMS Therapy to be effective, it should be performed on a routine basis for the complete treatment protocol of approximately 36 sessions. For self-pay patients, we will refund payment ONLY if we receive notice of cancellation at least seven (7) days before the date your initial (acute phase) treatment is scheduled to begin. No refunds will be given within seven (7) days before you are scheduled to start the initial, acute phase, treatment block.
2. Missing any treatment could affect your response to TMS and is not advisable. If you fail to cancel a particular day’s TMS treatment within 24 hours of that treatment, you will be charged a cancelation fee of $50.00. Clearwave, in its sole discretion, may choose to waive or reduce this cancellation fee, however, any waiver or reduction in cancellation fee shall not be deemed a change in the Cancellation Policy and Clearwave reserves the right to enforce its Cancellation Policy on all subsequent missed treatments. Please be advised that most insurance companies do not reimburse for missed appointments and therefore you will likely be personally responsible for any assessed cancellation fee.
1. All patients must have a valid credit card on file while undergoing TMS therapy. By signing this acknowledgement, you hereby provide Clearwave the authorization to charge your credit card for all sums owed at the time they become due, including applicable deductibles, copays, co-insurances and balance bills.
2. The patient is ultimately responsible for payment for TMS therapy. We accept most forms of payment. Payment for TMS therapy should be made to TMS Medical of the Hudson Valley, P.C. Returned checks will be charged the entire amount plus a $25 return check fee. Late payments will be charged interest at the rate of 1% per whole or partial month the payment is overdue, or 5% of the total bill, whichever is greater.
3. If you fail to timely make required payments, Clearwave reserves the right to pursue any and all means to collect outstanding payments. If Clearwave incurs any attorneys’ fees and costs in its collections efforts, you shall be responsible for reimbursing Clearwave for all attorneys’ fees and costs incurred to the extent permitted by law.
I acknowledge I have read this document and have been given an opportunity to ask questions. My questions have been answered to my satisfaction. A copy of this form has been made available to me.