Intake – $150
Session – $130
Extended Session for 15 minute increments $35 – *Not billed to Insurance
Paperwork – $100 – *Not billed to Insurance
Life Coaching – $130 – *Not billed to Insurance
Late Cancel (less than 24 hrs. notice) – $130 – *Not billed to Insurance
No Show – $130 – *Not billed to Insurance
Group Session – $40 – *Not billed to Insurance
All appointment fees including copays, coinsurances, deductibles, etc., will 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 at least 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 more than 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 any forms or paperwork for me I will request this a week in advance.
I will incur a charge starting at $100. 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.
RELEASE OF INFORMATION TO INSURANCE and PRIMARY BENEFICIARY
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.
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