No Surprises Disclosure

FEE AGREEMENT AND FINANCIAL POLICY

Thank you for choosing psychiatryhelps.com. Please review this Fee Agreement and Financial Policy (the “Agreement and Policy”), which describes our schedule of fees for services, charges not covered by insurance, and additional fees. Please be sure you understand the policies regarding cancelations and missed appointments, methods of payment, insurance reimbursement, and past due accounts. If you have any questions about anything, please ask your provider prior to signing this Agreement and Policy.

Our service rates and corresponding health insurance billing codes (numbers starting with '90' refer to mental health services) this is not a comprehensive list and reflects the most common services provided by our staff. Additional codes may be used by your provider as deemed appropriate. Costs are determined according to the provider’s level of training and licensure.

90792 Initial Consultation with Medical Evaluation (50-90 min.) $250

90838 Supportive Psychotherapy (60 min.) with medication management (99212-99215) $250

90836 Supportive Psychotherapy (40 min.) with medication management (99212-99215) $200

90833 Supportive Psychotherapy (30 min.) with medication management (99212-99215) $150

99212-99215 Medication Management $75-$250

CHARGES NOT COVERED BY INSURANCE

Medical Records Requests $15.00 per request

Case Management* $130.00 (pro-rated per 15 min.)

*Case Management includes indirect services I provide outside our session times such as writing letters,

consultations made at your request (for which a written authorization for disclosure of confidential

information is required), coordinating adjunct and Court Advocacy services, and completing forms or

reports. On occasion, you may request that we testify or be present in court proceedings on your behalf

of a subpoena from the court. The time billed will begin from our arrival at the courthouse to the completion

of testimony.

Phone Consultations (11-60 min.) $130.00 (pro-rated per 15 min.)

ADDITIONAL FEES

Late cancelations/Missed Appointment – Sessions that are canceled fewer than 48 hrs. prior to appointment or

“no shows”: Full fee according to the scheduled service.

Past-due accounts - over 30 days $25.00 per month

Checks returned due to insufficient funds will incur a fee of $50.00

PAYMENT

You will be expected to pay for either each session in full or your insurance co-payment at the time of services

provided under the Outpatient Services Agreement, which will be given to you along with this Agreement and

Policy and our Notice of Privacy Practices. Accepted methods of payment are cash, or credit cards. Credit card fees are 3% additional.

INSURANCE REIMBURSEMENT

Psychiatryhelps.com accepts and process insurance payments through a variety of insurance providers

and Employee assistance plans. If you are using insurance or an employee assistance provider to pay for

services, then we will:

(1) Expect and accept payment at the time of service

(2) File your claim with the insurance provider

(3) Receive payment from your insurance provider if we are in-network with that insurer. If we are out of network, we will file a claim on your behalf and your insurance

company may send you a check for the difference between our cash rate and your out of network benefits.

(4) Expect that you will pay your portion due of copay, co-insurance, deductible, or fee difference at the time of

your appointment.

PLEASE NOTE: YOU ARE REQUIRED TO SIGN EITHER THE PERMISSION TO SEND CLAIMS TO YOUR INSURANCE COMPANY SECTION OR THE PRIVATE PAY SECTION

Psychiatryhelps.com files insurance as a courtesy to you, and that YOU (not your insurance company) are ultimately responsible for your bill. If your insurance company denies a claim filed on your behalf, then you are responsible to pay psychiatryhelps.com for the difference between the standard rate and the amount previously paid as copay unless approved otherwise by owners of psychiatryhelps.com.

I agree to 

(1) allow psychiatryhelps.com to bill my insurance directly for services provided under the Outpatient Services Agreement; 

(2) give psychiatryhelps.com permission to release any information the insurance company may require in order to process payment; appoint psychiatryhelps.com as my authorized representative to act for me in obtaining payment; 

(3) assign all of my in network rights to claims and payment by my insurance to psychiatryhelps.com; and 

(4) agree to assist with the claims process as required by psychiatryhelps.com or my insurance provider. I understand that if my insurance plan requires that I meet a deductible amount prior to coverage by insurance, I will be responsible for the full session fee until the required deductible amount has been met. I acknowledge that not all issues, conditions, and problems dealt with in psychotherapy are reimbursed by insurance companies.

Client name:  

Client Signature

Private/Self-Payment for Services

I will self-pay for services at psychiatryhelps.com. I agree to the fee schedule in this document. I understand that payment for services is due at the time services are provided.

Client name:  

Client Signature

PAST DUE ACCOUNTS

Amounts past due by more than 30 days will incur a late fee each month of $25.00. If your account has not been paid for more than 45 days and arrangements for payment have not been agreed upon, The Source Behavioral Health may resort to legal means to secure payment. This may involve hiring a collection agency, an attorney, or going through small claims court.

If such legal action is necessary, you will be responsible for those costs.

Client Name: