Forms, Fees and Payment Policies
Forms, Fees and Payment Policies
Payment Policies and Insurance
I offer a few different payment plans to make my services affordable, as well as to accommodate those who do not have, or do not wish to use their insurance. I accept checks, cash or credit/debit cards. Payment is expected at each visit unless other arrangements are made with me in advance. Each month I will submit electronically for those who wish to use their health insurance and you will be reimbursed by them. I offer a discount to group clients who pay every six weeks.
Forms
New patients must complete all forms listed below.
NOTE: Please ensure pop-ups are allowed for this site, forms will open in a new window.
Credit Card Authorization
(NOTE: This form must be submitted separately. If you are having trouble locating the form after clicking the link, please check your downloads.)
No Surprises Act 2022
Effective January 1, 2022, the No Surprises Act requires health care providers to provide a “Good Faith Estimate” of expected charges to those who are uninsured or those who do not wish to use their health insurance plan.
The “Good Faith Estimate” is provided to help you estimate the expected charges you may be billed for receiving psychotherapy services. During your initial phone consultation, I will review and explain your expected medical care costs.
Additional Information:
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency services.
You have the right to receive a Good Faith Estimate in writing at least 1 business day before your service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to keep a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit http://www.cms.gov/nosurprises or call 1-800-985-3059.