STL Therapy Intensives LLC: Client Intake Form

Out-of-network provider(s) or facility name: STL Therapy Intensives LLC   17709 Old Ballas Road, Ste 203, St.Louis MO 63141    NPI #: 1841178670     EIN: 39-3888173

YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS (OMB Control Number: 0938-1401) When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing. What is “balance billing” (sometimes called “surprise billing”)? When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. “Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit. “Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care - like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. You are protected from balance billing for: Emergency services If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services. Certain services at an in-network hospital or ambulatory surgical center When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you unless you give written consent and give up your protections. You’re never required to give up your protection from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network. When balance billing isn’t allowed, you also have the following protections: • You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly. • Your health plan generally must: o Cover emergency services without requiring you to get approval for services in advance (prior authorization). o Cover emergency services by out-of-network providers. o Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits. o Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit. If you believe you’ve been wrongly billed, you may contact: Missouri Counselors Board 3605 Missouri Blvd Jefferson City, MO 65109 573-751-0018 Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.

Out-of-network provider(s) or facility name: STL Therapy Intensives LLC   17709 Old Ballas Road, Ste 203, St.Louis MO 63141    NPI #: 1841178670     EIN: 39-3888173

Total cost estimate of what you may be asked to pay: It is your ethical right to determine your goals for treatment and how long you would like to remain in therapy unless you are pursuing mandatory treatment. Please see the breakdown of possible fees listed below. ► Review your detailed estimate. See below for a cost estimate for each item of possible service. ► Call your health plan. Your plan may have better information about how much of these services are reimbursable. Prior authorization or other care management limitations Except in an emergency, your health plan may require prior authorization (or other limitations) for certain items and services. This means you may need your plan’s approval that it will cover an item or service before you get them. If prior authorization is required, ask your health plan about what information is necessary to get coverage. Your cost estimate may include these services:

90791 Diagnostic Assessment $150

90837 Psychotherapy (53 minutes and more) $150

90834 Psychotherapy (38-52 minutes) $120

90839 Psychotherapy for crisis (30-74 minutes) $120

90846 Family Psychotherapy without Patient Present (50 minutes) $150

90847 Family Psychotherapy with Patient Present (50 minutes) $150

98970-98972 Telephone Assessment & Management (prorated based on the time spent at hourly rate) (37.50 per unit, 1 unit=15 minutes)

Online Digital Evaluation & Management *responding to email & text messages* (prorated based on the time spent at hourly rate)  (37.50 per unit, 1 unit=15 minutes)

Late Cancel (48 hours notice required) or No Show Fee $150

FULL Payment is Required before the start time of the EMDR Group Intensive. A nonrefundable security deposit ($100) is due upon completion of paperwork. This secures your spot and ensures stability and quality therapuetic services. 

Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION.

As a therapy practice, we have always been held to the highest standards with regards to patient confidentiality.

STL Therapy Intensives, LLC pledges that we will follow government standards. We are required to post a list of your rights. We must give you a list of your confidentiality rights and ask that you read them. We must ask you to sign your name on this list as evidence that you have been informed of these rights. We must make it clear that we cannot withhold treatment if you refuse to sign the document.

Uses and Disclosures STL Therapy Intensives, LLC will use and disclose elements of your protected health information (PHI) in the following ways without your signed authorization.

1. If doctors/therapists outside our group are covering for doctors/therapists in our group, your PHI (if needed) will be forwarded to that doctor to ensure continuity of care. (For example: if you have a medical emergency, asking the covering provider to return your phone call, etc., your PHI may be forwarded to that doctor.)

2. If you are in an Emergency Room and your PHI is needed to assist in your care, your PHI will be forwarded to the Emergency Room staff.

3. In emergency situations or to avert serious health/safety situations.

4. When release is required by law, including judicial settings, health oversight regulatory agencies and law enforcement.

5. To medical examiners, coroners or funeral directors to aid in identifying you or help them in performing their duties.

6. To contact you about appointment reminders, treatment alternatives and other health related benefits and services.

7. To the spouse of your health plan.

8. For payment of services from insurance companies we are required to submit some portions of your PHI.

9. For payment of services that are sent to collection agencies we are required to submit some portions of your PHI

10. We submit our bill through a billing agency and clearinghouse. Some portions of your PHI are sent so health insurance plans will pay for the services you received.

YOU HAVE THE FOLLOWING RIGHTS CONCERNING YOUR PROTECTED HEALTH INFORMATION:

1. To request restrictions regarding the uses and disclosures of your protected health information. This request must be in writing. While you have the right to request restrictions, STL Therapy Intensives, LLC does not have to agree to the restrictions.

2. To request alternative means to receive confidential communications. The request must be in writing. Still Move Counseling, LLC may require a patient to provide information on how the patient will handle payment for the service.

3. To request amendment of protected health information. This request must be writing. For example, address change, phone number change, marital status, insurance coverage, inaccurate listing of medication, an incorrect or a change in Primary Care Physician.

4. STL Therapy Intensives, LLC may deny access to patients for the following reasons: A. PHI consist of psychotherapy notes B. PHI is compiled in reasonable anticipation of litigation C. PHI is maintained for CLIA Compliance D. Request for access to PHI is from a prison inmate E. PHI was created or obtained for current Research F. PHI is obtained from a non-healthcare provider under a promise of confidentiality G. Release of PHI is reasonable likely to endanger the safety of the individual H. PHI references another person that may result in harm to such person I. PHI has been requested by a personal representative of the individual and release may result in harm to such person

5. To request an accounting of disclosures of protected health information. This request must be in writing. The written account will provide: the date of the disclosure, the name of the entity receiving the PHI, a brief description of the disclosure.

6. STL Therapy Intensives, LLC does not have to account for disclosure when: A. Disclosure made to carry out treatment, payment or health care operations B. Disclosure made to patients of their own PHI C. Disclosure made pursuant to a patient’s authorization D. Incidental disclosures to an otherwise permitted use (i.e., conversations of PHI) E. Disclosure made to family or others involved in a patient’s care F. Disclosure made for national security or intelligence purposes G. Disclosure made to correctional institutions or law enforcement regarding inmates H. Disclosures occurring before April 14, 2003 I. Disclosures made to law enforcement of health oversight agencies when such officials have made a request suspend an accounting.

STL Therapy Intensives LLC does not provide emergency services. You will need to call 911 or 988 in the case that a mental health emergency arises. 

STL Therapy Intensives LLC does not provide ongoing therapeutic supports. If you are in need of ongoing, individual therapy, it is your responsibility to find and schedule appointments as you see fit. 

At any point in the EMDR Group Intensive, the primary therapist may deem this intervention as ineffective and may refer you to individual EMDR Intensives or EMDR Individual therapy. Referrals may be provided to you at that time. 

You may contact the secretary of the United States Department of Health and Human Services with questions or to register complaints about any licensed mental health professional.

Please type your name below to indicate consent to treatment.

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If patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.