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Palmentera & Associates, Inc.
Policies and Procedures
FEES: Our current fee is $120 per
session. The initial session is $130 for adults and $135 for children,
adolescents, and/or families. Court-related cases are $160 per session.
The “intake process” is three sessions and is used to determine the
clinical needs of each individual and the “fit” with the therapist. The
duration of a session is 50 minutes which is known as the “clinical
hour.” Payment is expected at the end of each therapy session unless
prior arrangements have been made. Any changes in this agreement must be
approved by your therapist.
ADDITIONAL CHARGES: We will charge for phone calls or preparation
of insurance claims if they exceed 15 minutes and will be billed at the
half-hour rate of $60. Occasionally, scheduled session time will be
devoted to filling out insurance forms in order to minimize costs, and
to keep you fully informed of what is disclosed to your insurance
company, this cost is not covered by insurance companies.
When psychological tests are administered, or if reports of any kind are
prepared for another party or you, there will be an additional charge of
$150. If you are not sure if this applies to you, please ask your
therapist.
Phone sessions will be billed at the standard therapy session rate in
half-hour increments when they exceed 15 minutes.
There will be a $33 charge for returned checks. A finance charge of 2%
per month will be calculated on all balances over 90 days due.
MISSED & CANCELLED APPOINTMENTS: Since scheduling of an
appointment involves the reservation of time specifically for you,
missed appointments and cancellations less than 24 hours prior to the
scheduled appointment will result in a charge for that time. Our phone
is answered 24 hours per day and a message is sufficient notice during
times when the office is closed.
FAILURE TO PAY YOUR BILL: Financial hardships may occur to any of
us. These hardships should be discussed with your therapist, so that
necessary changes in your payment agreement can be made. Non-payment may
result in collection efforts or legal action. Of course, this is a
regrettable action used only when other efforts have failed. If an
account is sent to collection, you will also be held financially
responsible for all collection fees assessed to our practice.
Some insurance carriers select a panel of providers to deliver therapy
services and may not reimburse for services from other professionals
outside their network. If you choose to pay for your services directly
and submit your claim to your insurance carrier, we would highly
recommend that you contact your insurance representative for
pre-approval to confirm your coverage, and any limitations, including
co-pays and deductibles.
CONFIDENTIALITY: Information revealed in your session is
confidential and will not be released to others without your permission.
There are some exceptions to this policy. If you were referred by your
physician for a consultation, we may be requested to send information
back to your physician so your complete physical and mental health can
be coordinated. If your health insurance is a managed care program, they
will request information so payment for services rendered can be
approved. However, prior to disclosure of any information, you will be
offered the opportunity to sign a release of information form. If you
have concerns about this information, please discuss it with your
therapist. Several legally required exceptions to confidentiality
include situations of potential harm to oneself or others, incidents of
child abuse (Ohio has a mandatory child abuse reporting law), incidents
of elderly or dependent abuse and situations where a court may order
records.
PAYMENT AGREEMENT
As a client of Palmentera & Associates, Inc. I understand that I am
financially responsible for professional services received by me or
those for whom I am responsible. It is my intention to carry out my
financial responsibility to Palmentera & Associates, Inc. in the
following manner:
______ I will pay for all professional services at the time they are
offered. I will file my own insurance claims and request that Palmentera
& Associates, Inc. provide me with statements and receipts. (Note: All
court-related services fall into this category.)
_______ Other (please specify) / Comments:
I understand Palmentera & Associates’ Inc. service, fee and payment
policies and agree to comply with these conditions. I understand all
charges for services rendered are my responsibility.
Name of Client: _________________________________________
Date of Birth: ___________________
Signature of Client/Responsible Party:
____________________________________
Date: _________________________
Signature of Therapist: ________________________________________________
Date: _________________________
©Palmentera & Associates, Inc. |
