PATIENT INFORMATION FORM - Please complete the Patient Information Form, which includes demographic,emergency, and insurance information. This will ensure correct billing to your insurance carrier. In the event your insurance changes and you do not notify us of the change in time for us to obtain authorizations or file claims within your insurance company’s timely filing deadlines, any unpaid fees will become the subscriber’s responsibility.
NEW CLIENTS - All new clients are asked to pay the full amount of their first visit at the time of that visit. Insurance will still be billed, and any over payment will be applied to future sessions.
INSURANCE PLANS - We accept most insurance plans. However, it is your responsibility to check with your insurance company prior to treatment to determine if your policy covers our providers and services. In many cases,insurance companies request pre-authorization prior to seeking treatment. It is your responsibility to obtain this pre-authorization. • United Health Tricare– Some of our services require a medical doctor referral. This will be requested prior to your scheduled appointment. It must be sent to Continuing Hope Counseling before services take place in order to prevent denial of services and the balance fall due to the client. If you are an Active-Duty service member, you must secure an authorization before your first visit.
BENEFITS INTERPRETATION - We will do our best to help you understand and interpret your health care benefits. However, it is ultimately your responsibility to understand which services are covered and which are not under your plan. If you have any questions, please contact your insurance carrier to help you with this process.
FISCAL YEAR DEDUCTIBLES - It is our policy at the start of each insurance plan’s fiscal year to collect the full amount billable for your visit at the time of your visit until your deductible has been met. Once verification of having met your deductible is made, you will only need to pay your insurance plan’s required co-payor percentage due.
INSURANCE BILLING - If it is determined that your insurance is one that is accepted by Continuing Hope Counseling, we will, as a courtesy, bill this company for you. If your insurance does not pay for any reason and an appeal is needed, your signature on this Financial Policy form serves as a waiver for your insurance company to grant us permission to file one appeal on your behalf.
MULTIPLE INSURANCE COVERAGE - For those with secondary or tertiary insurance coverage, we will bill your primary insurance first. Once payment is received from that primary insurance company, we then will bill your secondary insurance company one time. Please remember that insurance is a contract between you and your insurance. We are happy to help as much as we can to ensure payment of your benefits; however, we cannot and will not become involved in disputes concerning deductibles, co-payments, secondary insurance, or what insurance companies refer to as “usual and customary”reductions.
CO-PAYMENT/CO-INSURANCE – After you have met your insurance company’s deductible, you must pay all required co-payments or co-insurance payments at the time of your appointment.
TELE-HEALTH SERVICES – When requested by the client and clinically indicated, services may be provided via tele-health in lieu of in-person appointments. In the instance of some insurance policies, tele-health benefit may be covered differently. It is your responsibility to check with your insurance company prior to treatment to determine if your policy covers tele-health appointments.
CANCELLATION POLICY – Continuing Hope Counseling requires 24-hour notice for appointment cancellations. A late fee of up to the total cost of the session may be incurred. Payment of late fees is required before additional appointments are made.
COURT TESTIMONY– For any employee who must testify in court, Continuing Hope Counseling charges five hundred dollars ($500.00) per hour, for testimony and three hundred and sixty dollars ($360.00) per hour for preparation, with a minimum charge for one hour.
RETURNED CHECKS – There is a $50.00 charge for all returned checks.
BALANCES OWED AFTER INSURANCE HAS PAID – If there is a balance owed after your insurance(s) has paid, you are responsible for payment of this balance. If we know what this balance will be at the time of your appointment, you are expected to pay at that time. Otherwise, we will send you a statement in the mail.Payment is due upon receipt. Continuing Hope Counseling reserves the right to discontinue services to you if your account is more than thirty (30) days past due or to refuse services if payments owed at the time of a scheduled service are not paid. Accounts more than ninety (90) days past due or with undeliverable addresses may be forwarded to a collection agency for recovery.
REFUND REQUESTS – Clients who have a credit on their account and would like that amount refunded to them must complete a Refund Request Form available from the Front Office staff. Refunds will be made only if the account stands at a zero balance. If it is determined there are other outstanding balances on your account, the requested refund will be applied to the outstanding balance. You must allow up to thirty (30) days from the time the refund is requested to receive the funds.
ACCOUNT RESPONSIBILITY – It is our policy to bill the insurance subscriber for any balances left on accounts.“Accounts” include services rendered to you, a spouse and/or dependents. If any responsible party fails to make timely payments on their portion of the account, we reserve the right to refuse treatment. If you do not have insurance, you are personally responsible for your own debt, and payment is expected at the time of service. In the case of minor patients with no insurance, the adult accompanying the patient is responsible for payments due at the time of service.
CLIENT ASSISTANCE PROGRAM – Our client assistance program is available to those who qualify. Paper work for this program may be obtained from our Front Office staff and on our website. Once completed and returned with the supporting financial information, the packet will be reviewed for approval. You will be advised of the amount of financial assistance for which you qualify. That amount will be good for a 3-month period, at which time reapplication will be needed if assistance is still desired.ELECTRONIC STATEMENTS – Billing statements are provided monthly.
ELECTRONIC STATEMENTS – Billing statements are provided monthly via email or text message to information account stands at a zero balance.
NO SURPRISES ACT – The No Surprises Act requires good faith estimates from a convening provider to include any item or service that is reasonably expected to be provided in conjunction with a scheduled or requested item or service by a co-provider or co-facility. Anticipated service fees are included on the Billing Information section of this intake packet. For any questions on fees for services, please speak with your provider or Continuing Hope Counseling Staff.