Dialectical Behavioral Therapy
Christian Couples Counseling
Miranda N. Dennis
Rates and Insurance
Office Policies & Informed Consent for Psychotherapy
This form provides you, the client, with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA preemptive analysis.
All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law.
WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW:
Some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled; or when a client's family members communicate to Oasis Clinical Counseling Services (OCCS) physicians, clinicians and staff that the client presents a danger to others. Disclosure may also be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony from Oasis Clinical Counseling Services (OCCS) physicians, clinicians and staff. In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. OCCS will use clinical judgment when revealing such information. OCCS will not release records to any outside party unless we is authorized to do so by all adult parties who were part of the family therapy, couple therapy or other treatment that involved more than one adult client.
If there is an emergency during therapy, or in the future after termination, where any Oasis Clinical Counseling Services (OCCS) physicians, clinicians and staff becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, we will do whatever we can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, we may also contact the person whose name you have provided as an emergency or on the biographical sheet.
HEALTH INSURANCE & CONFIDENTIALITY OF RECORDS:
Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. Only the minimum necessary information will be communicated to the carrier. Oasis Clinical Counseling Services (OCCS) physicians, clinicians and staff have no control over, or knowledge of, what insurance companies do with the information we submit or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or even a job. The risk stems from the fact that mental health information is likely to be entered into big insurance companies' computers and is likely to be reported to the National Medical Data Bank. Accessibility to 2 companies' computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to hacking and unauthorized access.
Oasis Clinical Counseling Services (OCCS) physicians, clinicians and staff consults regularly with other professionals regarding clients; however, each client's identity remains completely anonymous and confidentiality is fully maintained.
PAYMENTS & INSURANCE REIMBURSEMENT:
Regarding insurance, please see our financial and office policy. We will file your insurance claim as a courtesy to you. Please notify OCCS if any problems arise during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Insurance companies do not reimburse all issues/conditions/problems that are dealt with in psychotherapy. It is your responsibility to verify the specifics of your coverage. If your account is overdue (unpaid) and there is no written agreement on a payment plan, OCCS can use legal or other means (courts, collection agencies, etc.) to obtain payment.
If you have medical insurance, we are eager to help you receive your maximum allowable benefits. In order to achieve this goal, we need your assistance and your understanding of our payment policy:
• Your bill is based on the services you received. You are responsible for paying the bill if your insurance company does not cover all the costs.
• What your health insurance covers is based on an agreement between the company, or person who employs you, and the insurance company.
• It is the patient’s responsibility to contact their insurance company with any questions about what they will cover.
• We know that temporary financial problems can sometimes prevent you from making a payment on your account on time. If this happens, you need to contact us at 757-271-9030 at once so we can help you with this problem. The billing department will help to arrange a payment plan.
• Any bill not paid by the date it is due will be sent to a collections agency.
IF YOU DO NOT HAVE HEALTH INSURANCE
• You must pay your entire bill at the time of service or inform us of your inability to pay.
• The OCCS billing department is available to discuss financial options with you at 757-271-9030
IF YOU HAVE HEALTH INSURANCE
We participate with several insurance companies. This means we have signed a contract with them to provide care for the people they cover. The contracts are not all the same, and certain services may not be covered depending upon your benefits.
If we DO participate with your insurance plan:
• You must pay any co-payment at the time you receive the service.
• You must pay any deductible amount or any amount that you know is not covered at the time of service.
• You must pay the amount not paid by your insurance. Payment is due upon receipt of the statement. If you do not pay we will begin collection efforts.
We will send a bill to your insurance company for all services done in our office.
If we DO NOT participate with your insurance plan:
You must pay for the service at the time it is given. Our office accepts cash, Ivy Pay, HSA, VISA, MasterCard, Discover, and American Express.
After you have paid us, we will provide you with a detailed receipt (Super Bill) upon your request. You will then submit the Super Bill to your insurance for reimbursement. All clients are required to have a credit/debit card on file through our secure card processing service. This will allow charges to be made on the day of your appointment. If you have purchased a monthly package or in the event of late cancellation or no show.
Financial Policies Agreement
STATEMENT OF FINANCIAL RESPONSIBILITY
In accordance with the OCCS financial policies above, the patient (or patient’s legal guardian) (hereinafter I, me, my, etc.) hereby understands and agrees to the following terms:
1. I accept financial responsibility for all clinical and administrative services provided by Oasis Clinical Counseling Services.
2. I authorize payment to Oasis Clinical Counseling Services for all services rendered. I authorize the use of this signature on all my insurance submissions whether manual or electronic.
3. I understand and agree that all ancillary services that are provided will be billed at the provider-specific hourly rate as noted below. Ancillary Services are defined as patient-initiated services which are not part of an initial assessment nor provided as part of a scheduled appointment. These services are not covered by insurance and involve an exchange of information, performed by the physician, psychologist, social worker, nurse practitioner, or therapist at OCCS. Examples of ancillary services include but are not limited to: All patient related phone calls including phone consultations with patient or family members, physicians, therapists, psychologists, school officials (administrators, teachers, counselors, etc.), attorney, etc., crisis counseling on the phone, email correspondence, time associated with preparing for non-appointment medication refills, completion of any forms during non-appointment times, etc. This does not include communication with the administrative staff. Legal and court related matters are billed at a higher rate and require a prior contract and retainer.
ANCILLARY SERVICE RATES:
Master’s Level Clinicians $120/53 mins
Supervisees/Residents $75/53 mins
• Legal services are billed with a 4 hour minimum requirement (including travel and wait time), and billed in 15 minute increments.
4. I understand and agree that if my account goes to a third party for collections; I am responsible for all fees incurred.
5. I understand and agree that if I have a balance on my account that it needs to be paid before my appointment and that failure to pay the debt may result in me not being seen and a missed appointment fee being added to my account. PLEASE NOTE: If you are unsure of your balance you may call OCCS.
By electronically signing this form below, I acknowledge that I have read, fully understand and agree to abide by the policies and fees in this agreement.
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Electronic Signature (Initials)
Oasis Clinical Counseling Services
Norfolk, VA and Phenix City, AL
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Dialectical Behavioral Therapy
Christian Couples Counseling
Miranda N. Dennis
Rates and Insurance