Welcome to our practice. We look forward to working with you. Please read this document carefully since it contains important information about our professional services and business policies. If you have any questions, please feel free to discuss them with us.
You should be aware that coverage for mental health services is not necessarily the same as for medical services, and that there may be restrictions on which type of mental health services are reimbursable. We recommend that clients inform themselves of all aspects of their insurance policy coverage, including deductible, copayment schedule, authorization/pre-certification requirements, and any service limitations.
It is the responsibility of the patient to provide to IFC their current insurance information at the time of the initial appointment.
Additionally, the client must notify us as soon as possible of any insurance policy changes. Even minor alterations in a policy can change reimbursement substantially. IFC cannot be held responsible for inaccurate billing if we are not informed of insurance changes. When appropriate, we will be happy to update our billing fees from the time of notice going forward.
Any services outside the scope of the contract or carrier approval are the responsibility of the client at non-contract rates. (For example, we cannot bill insurance companies for school visits or written correspondence.)
Appointments canceled with less than 24-hour notice will result in a charge reflective of your fee unless you are canceling due to illness or emergency. Cancellation charges cannot be billed to insurance.
The client should assume that, regardless of their insurance status, they are ultimately responsible for any outstanding account balance for services rendered.
Once treatment is terminated, all outstanding bills must be paid within 60 days. Beyond 60 days after treatment termination, overdue balances may be subject to a monthly finance charge of 2%.
You are expected to pay for services (full or co-payment as agreed) at the end of each session. If you are covered by health insurance, we can submit claim forms directly to your insurer upon your request. Please make all checks out to The Institute for Change. You may also pay by credit card (processing fee applies) or via Zelle (Our Zelle ID is: email@example.com)
Thank you for following our practice guidelines. We look forward to working with you.
You may either print this form and bring your signed form to your first appointment or we can provide the form to you at our office.
By signing below, I acknowledge that I have read and understood the above policies and agree to follow them.