Intake – $150
Session – $130
Extended Session for 15 minute increments $35
Paperwork – $100
Life Coaching – $450 monthly (includes up to 5 hours of face to face or VSee video, email or phone consultation.
Late Cancel (less than 24 hrs. notice) – $130
No Show – $130
All appointment fees including copays, coinsurances, deductibles, etc., are expected to be collected at the time of service.
If we are unable to collect payment from your insurance company within 90 days you will be personally responsible for the amount owed. This balance will need to be paid in full or a payment agreement established prior to further appointments being attended.
All payment agreements will be documented on the credit card payment consent form and will be automatically charged to the account you provide as established on the agreement.
If you are unable to attend an appointment we request that you provide 24 hours advance notice to our office. Since we are unable to use this time for another client please note that you will be billed for the entire cost of your scheduled appointment if 24 hours advance notice is not provided. I understand that I will need to pay the missed appointment fee before I can attend another appointment and that my medical insurance will not cover this cost. We appreciate your help in keeping the office schedule running timely and efficiently.
FEES FOR PAPERWORK
I understand that if I need my provider to complete paperwork for me I will request this a week in advance and I will incur a charge of $100 per hour of preparation time. I understand that my medical insurance will not cover this and I will need to pay this fee prior to receiving my completed requested documentation. EXCEPTIONS-simple forms which can be quickly completed will be provided at no charge and this will be determined by your individual provider.
RELEASE OF INFORMATION TO INSURANCE and PRIMARY BENIFICIARY
I agree for Refreshing Waters Counseling & Consulting to bill my medical insurance for services provided. I agree for Refreshing Waters Counseling & Consulting to contact the primary cardholder of my insurance card, regarding the dates that I received service, for the purpose of notifying cardholder of copays, deductibles and payments due. In such instances no specific details of my care will be disclosed. BALANCES DUE Any balance over 90 days may be turned over to a collection agency. Please let us know if you are experiencing financial difficulty and we will set up a payment plan with you. By signing I agree to the above information and understand their meaning and ramifications