FEES AND INSURANCE INFORMATION

All new patient appointments are 60 minutes. The fee for self-pay new patients is $400.00. The fee for self-pay of a 40 minute follow up appointment with psychotherapy is $250.00. The fee for self-pay of a 30-minute follow up appointment is $200. The fee for self-pay of a 20 minute follow up appointment is $175.00. The fee for self-pay of CNS VS testing is $400.00. At this time, we are currently in network with Aetna, BCBS*, Cigna (EverNorth), Medcost, Medicare, Multiplan, and United (Optum) insurance plans. As a courtesy to you, we will file claims for your sessions electronically; however, payment of all applicable co-pays, co-insurances and deductibles are required prior to the scheduled appointment time. IBHHP will charge for upcoming appointments approximately 24 hours in advance of the appointment.
We will not be able to file claims with your insurance company unless you provide complete and accurate information about your insurance. It is your responsibility to ensure that we have the correct information and that you promptly inform the practice of any changes in your coverage. If, for any reason, your insurance company does not reimburse Integrative Behavioral Health & Healing Practice for services rendered, you will be responsible for those charges. Attempts to collect this balance will be made for 30-90 days past due. Any balances that age past 90 days will be transferred to a collection agency.

*While we are in network with nearly all BCBS plans, we do not accept BlueHome/UNC Health Alliance. This is a restricted plan that would be out of network. Patients with this plan will be self-pay and claims will not be submitted.

PAYMENT INFORMATION

All co-pays, co-insurances and deductible payments will be processed through XPressPay through First Citizens Bank, a secure, online payment platform. The amount you owe for your visit will be automatically deducted approximately 24 hours prior. At the time of scheduling your first visit you will be required to provide the debit or credit card that you wish to be stored for payment purposes. If for any reason you do not have an up-to-date payment method on file and a successful payment has not been made for your appointment, please note your appointment will be cancelled and may result in a fee.

NO-SHOWS & LATE CANCELLATIONS

All cancellations need to be made by phone call or email more than 24 business hours prior to your appointment time. This includes weekends if your appointment is on a Monday. If you fail to cancel your appointment with more than 24 business hours notice, you will be charged a cancellation fee of $400 for new patient appointments and $175-$250 for office visits, depending upon the allotted time for your appointment. Insurance companies will not pay for missed appointments and you will be held responsible for the full (above) cost of the missed appointment. Additionally, if you are more than 10 minutes late for your appointment, you will have to be rescheduled and the late cancellation fee will be applied to the card on file.

EMERGENCIES

For after hour emergencies ONLY you may contact our on-call provider on weekends at the following number (984) 288-0880. Please note a charge will be applied for contacting the on-call provider.

If you are experiencing an emergency, please call 911 or go to the nearest emergency room. Emergency situations include serious psychiatric medication reactions or risk of harm to oneself or someone else.

PRESCRIPTION REFILLS

Refills of medication are usually written at the time of your appointment. If you are in need of a refill between appointments, please contact your pharmacy, and they will fax a refill request allowing 72 hours for refills to be completed. If it is a refill for a class II controlled substance (ADHD stimulants) call the office at 984- 288-0880 and request a refill. Refills are not considered an emergency and will be handled during regular business hours of 7:40am and 4pm, within 72 business hours.

If you contact the after-hours emergency on call provider on weekends for a refill a charge will be applied to your card. All controlled substance refills require the patient to have been seen in an appointment within the past 3 months. The patient will not be granted a refill until seen in an appointment past this time. It is the responsibility of the patient to ensure following up to appointments.

TREATMENT OF STAFF

Staff have the right to work in a safe and secure environment and we as employers have the legal responsibility of providing that environment. The Practice will not tolerate:

• Verbal abuse to staff which prevents them from doing their job or makes them feel intimidated or unsafe
• Threats of violence or actual violence to any member of the Practice

Our Practice staff aim to be polite, helpful, and sensitive to all patients’ individual needs and circumstances. They would respectfully remind patients that very often staff could be confronted with a multitude of varying and sometimes difficult tasks and situations, all at the same time. The staff understand that ill patients do not always act in a reasonable manner and will take this into consideration when trying to deal with a misunderstanding or complaint.

However, aggressive behavior, be it violent or abusive, will not be tolerated and may result in you being immediately terminated from the practice.In order for the practice to maintain good relations with their patients the practice would like to ask all its patients to read and take note of the occasional types of behavior that would be found unacceptable:

• Using bad language or swearing at practice staff
• Any physical violence towards any member of the Primary Health Care Team or other patients
• Verbal abuse towards the staff in any form including verbally insulting the staff
• Racial abuse and sexual harassment will not be tolerated within this practice
• Persistent or unrealistic demands that cause stress to staff will not be accepted. Requests will be met wherever possible and explanations given when they cannot
• Obtaining drugs and/or medical services fraudulently
• Treat your provider and their staff courteously at all times.

Your signature below indicates that you have read this agreement and agreed to all of its terms. You understand that if the terms of this agreement are violated, your treatment in this practice may require termination. Your signature also serves as an acknowledgement that you have received the HIPAA Notice of Policies and Practices described above if you have requested it or agreed to review it on my website.

LIMITS OF CONFIDENTIALITY

Treatment is confidential, with the below stated exceptions.Duty to Warn: medical providers are mandated by law to disclose pertinent information discussed in appointments if the patient:

1. Has intent or plan to harm another person. We are required to inform the intended victim and notify legal authorities.
2. When there is reasonable cause to believe child/elder abuse or neglect has occurred.
3. When an emergency situation requires sharing of information.
4. When required for insurance billing purposes.

5. When a court order is received.

By signing, I acknowledge that I have read, understood and agree to the items contained in this document. If the patient is a minor, lacks legal capacity or is unable to sign, an authorized personal representative may sign this form.