FINANCIAL POLICIES AGREEMENT

This form has a lot of questions pertaining to your insurance, personal responsibility of your payments, your insurance, and addresses our financial policies. Do not sign this unless you have read and understood it completely as we enforce these policies strictly. 

A. Insurance Policy:

If there is a change in insurance, please notify our office immediately. If there are copays, co-insurance, or a full deductible, payment is expected at the time of service. 

If the insurance denies the claims for reasons related to invalid insurance (whether by lack of knowledge on your mental health plan, or errors), or because you were given care as insured in-network but your plans deems it out-of-network, you will be responsible for paying the cash rate (see rates in D, below)

B. Uncovered Medical Services

Some services are not paid by insurance companies, but patients or their
representatives may occasionally request the physician to perform these services to coordinate care with other organizations or to offer consistent and quality care on your behalf. These services take up the physician's time and therefore the following services are billed at a pro-rated hourly rate (charged in 15 minute intervals) of $475, much the way attorneys charge. Some examples of these services are:

• Preparation of reports or completing documents for other providers, organizations, disability claims, insurance reviews, landlords, and others.
• Telephone calls lasting more than 5 minutes.

C. No-Show/Late-Cancel Fees

A No-Show is a failure to show to a scheduled appointment within 5 minutes of start time for a visit 15 min or less and within 10 minutes of start time for a visit of 25 min or greater. 

A Late-Cancellation is a failure to cancel an appointment within 1 full business day or 24 hours, whichever is greater. 

Fees for patients who No-Show or Late-Cancel are not reimbursed by insurance companies and are the personal financial responsibility of the patient. These fees apply to all patients, even if they do not have insurance. Fees can be waived with a valid physician's note or extenuating circumstances. 

• A No-Show/Late-Cancel of a new intake or extended session (45-60 min) will be assessed a fee of $400.
• A No-Show/Late Cancel of a follow up appointment of 25 minutes will be assessed a fee of $250. 
• A No-Show/Late-Cancel of a follow-up appointment of 15 minutes or less will be assessed a fee of $175.

IMPORTANT NOTE: if you show up to your scheduled visit but you are not in a state where the physician is licensed, the visit is considered a late cancel as you cannot be seen. It is your responsibility to be in the state where you originally listed. If you plan on a vacation or an extended trip, speak to our staff to see how we can help.  

D. Cash Pay/Uninsured/Out of Network Payment:

Payment in full is due at time of service. We are able to provide you with a "superbill" to submit to your insurance for partial reimbursement. Contact your insurance for questions about out-of-network benefits and amount of reimbursement.

Rates are as follows, and will be based on your appointment booking, even if you decide not to use your entire time alloted):

• Initial Appointment (55 minutes): $475 ($375 must be pre-paid to hold the spot in case of a no-show)
• Psychotherapy visit (55 minutes): $475
• Extended visit (45 minutes): $400
• Extended med-check (up to 25 minutes): $300
• Brief med-check (up to 15 minutes): $225

E. Payment and Credit Card Authorization:

If a deductible/copay/coinsurance applies we will charge it at the time of your visit.  

We accept most credit cards, PayPal (pay@lifetimeinsight.com), or Zelle (pay@lifetimeinsight.com). We do not accept any other form of payment.

All patients are required to provide us with a credit card number which we leave on file. Your credit card will be used to secure payment for unpaid balances over 30 days, and for No-Show/Late Cancel fees will be charged on the day of the visit. A refund will be provided should a No-Show/Late-Cancel fee is deemed emergent. The practice retains the right to charge your credit card automatically if any of the above fees apply. If your credit card fails for payment, and your balance is more than 30 days, no further visits will be scheduled and your account may be sent to Collections. 

F. Reasons for Termination:

Three No-Shows/Late Cancellations or an inability to meet financial obligations may result in termination from the practice. Patients who have outstanding payments over 90 days will be termianted due to lack of trust/rapport. Other reasons are abusive or inappropriate behavior, lack of follow-up, or when the doctor-patient relationship is poor. You will be given notice of termination through the secure patient portal with instructions on transferring care and any refills, if necessary. 

G. Forensic Services:

Court-ordered and all legal-related services, including assessments and reports used for court or a legal matter, preparing for depositions, court time, and travel expenses related to the above are considered forensic-type services and are not done by this office. We recommend you seek out a forensic psychiatrist who can prepare reports and testify if necessary. 

H. Collection Services:

All accounts past due by over 90 days will be turned over to collections. If you are having trouble paying your bills, please avoid collections by requesting a payment plan. The payment plan will be through PayPal. While we may not always be able to accomodate, we will certianly do our best. We will avoid sending you to collections if you show a good effort to pay your bills.