Your Agreement with Mind Therapy Clinic
Welcome! We've found it helpful to outline our office policies in writing. Please take a few moments to review the following information and ask us any questions you may have.
The Intensive Outpatient Program (IOP) is priced based on monthly attendance. If we are seeking insurance reimbursement on your behalf, please know that they do not reimburse for missed sessions, and you will need to cover those costs.
There is a $20 service charge applied to your account for each returned check to cover the costs of processing and any penalty charged incurred by the clinic.
Should your account become sixty (60) days delinquent, one and one half percent (1.5%) finance charge per month will be added to your bill. Services may be discontinued and your outstanding charges may be turned over to a collection agency. Should this happen, you will be responsible for the costs incurred in the effort to collect payment including but not limited to legal fees and other collection costs.
LIMITS OF CONFIDENTIALITY STATEMENT
All information between practitioner and patient is strictly confidential. Legal exceptions include:
- The patient is minor.
- The patient authorizes a release of information with a signature.
- The patient's mental condition becomes an issue in a lawsuit.
- The patient presents as a physical danger to self or others.
- Child or elder abuse and/or neglect is suspected.
- Medical emergencies.
- Any official review of the services provided (if you have signed a release authorizing a review, such as insurance information forms. In the case of #3 or #4 above, Mind Therapy Clinic is required by law to inform potential victims and legal authorities so that protective measures can be taken.
CELL PHONES, FAXES, EMAIL
It is important to note that cell phone and email communication may not be secure. Faxes can also be easily sent to erroneous numbers. If you are using a cell phone while communicating with our office, you must be aware that we cannot ensure the confidentiality of the call. If you use email to communicate with Mind Therapy Clinic, we will assume that you have made an informed decision that you are taking the risk of such communication being intercepted. Please do not communicate an emergency by email or fax.
It may be necessary at times for our office to leave you a message at the phone numbers you provide us. By supplying us with specific phone numbers, you authorize Mind Therapy Clinic to leave messages for you at those numbers.
We try to service our clients whenever possible; however we are not a 24-hour facility. In case of an emergency, if you are unable to talk with your provider, call 911 or go to the nearest emergency room. If you leave a voice message with Mind Therapy Clinic, and do not receive a returned call within two (2) hours and feel it is an emergency, call 911 or go to the nearest emergency room.
CONSENT FOR TREATMENT
I hereby consent to be treated by Mind Therapy Clinic. I authorize and request my practitioner to carry out psychological exams, treatment and/or diagnostic procedures, which now, or during the course of my treatment, become advisable. I understand the purpose of these procedures will be explained to me upon my request and that they are subject to my agreement. I also understand that while the course of my treatment is designed to be helpful, my practitioner can make no guarantees about the outcome of my treatment. Further, the psychotherapeutic process can bring up uncomfortable feelings and reactions such as anxiety, sadness and anger. I understand that this is a normal response to working through unresolved life experiences and that these reactions will be worked on between my practitioner and me.
MIND THERAPY CLINIC HOLIDAYS
The Mind Therapy Clinic will be closed on the following holidays: New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and the day after, Christmas Eve and Christmas Day.
LEAVE OF ABSENCE REQUESTS
Patients planning to be absent must complete the clinic's Leave of Absence Request form at least two weeks prior to the date of absence. Mind Therapy Clinic does not excuse absences of less than one (1) week of treatment. Additionally, patients are financially responsible for all unexcused absences.
ELECTRONIC RECORD KEEPING SYSTEM
Mind Therapy Clinic uses Electronic Medical Records (EMR) to securely maintain your health care information, and I understand that my healthcare information is maintained in this electronic medium.
I understand that my financially responsible party and/or I am responsible for payment of all fees. IOP monthly fees are paid at the beginning of each month. I agree to pay for all services rendered. I understand that Mind Therapy Clinic may be billing my insurance to obtain reimbursement for the fees I have paid. I will be informed in advance about whether Mind Therapy Clinic can bill my insurance and whether my benefits may cover Mind Therapy Clinic services. I also understand that insurance reimbursement cannot be guaranteed by Mind Therapy Clinic and that I am paying for services knowing only a portion or none of the services might be reimbursed. I agree to pay for any additional agreed upon clinical services outside the basic IOP package at Mind Therapy Clinic's usual rates in addition to the monthly IOP charge. These charges are due at the time of service. There will be a negotiated discount for those continuing in IOP after the initial first three (3) months.
If the patient is eligible for out-of-network coverage for the IOP, Mind Therapy Clinic will submit a claim to insurance on the patient's behalf. The reimbursement for that coverage will be sent to Mind Therapy Clinic, which will then reimburse the patient the full amount of the funds received from the insurance company up to the 90% of the amount that has been paid to Mind Therapy Clinic.
I understand that Mind Therapy Clinic will bill me directly for any balances due from me that are not collected at the time of service, including, but not limited to, charges unpaid or missed appointments. I understand that if I fail to make payment on any balances due from me or make satisfactory payment arrangements with Mind Therapy Clinic for any balance due, they may turn my account over to a collection agency. I also understand that if any checks are returned by the bank for non-payment, that amount plus the $20 service charge will automatically be charged to my account.
I hereby consent to the release of information by Mind Therapy Clinic staff to any parties responsible for payment for my care any information deemed essential to insure payment to Mind Therapy Clinic and continuation of necessary treatment services. Generally, this is limited to attendance, program schedules, and fees.
By signing below, I certify that I have read and understand this agreement and have full knowledge of its meaning and effect.