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Please read the following information carefully:

 

SESSIONS AND FEES ( SUBJECT TO CHANGE):

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Individual Diagnostic- $175.00

Individual 53 -minute sessions are $115.00. 

Family 53 -minute sessions are $150.00 (There is an additional fee of $25.00 for each additional person after the third person)

 

Missed sessions without 24 hour notice will be billed according to the above fee schedule.

 

ACCEPTABLE METHODS OF PAYMENT: CREDIT CARDS, CASH AND CASHAPP ( $CARELCSW)

 

PAYMENT:

• Payment for all services is expected at the time of all office visits.  Fees will be established during the course of your first visit.  We do not file insurance claims for outpatient services, except for insurance companies of which Crystal Ward is a provider. You can be provided receipts which when submitted to your insurance carrier will provide sufficient documentation for you to be reimbursed directly.

• If Crystal Ward or a C.A.R.E Counseling Representative has contracted with your insurance to file insurance claims and you wish your claim to be filed, you must sign the consent to release information to your insurance company. Please bring your insurance card with you to be photocopied for our files. It is often 8-12 weeks or longer before claims filed on behalf of our patients are honored.  The insurance form specifically must be filled in through both of the signature lines to signify assignment of benefits. At times, we provide courtesy billing, however ,YOU are responsible for pre-authorization with your insurance company.

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I AM A MEDICARE AND MEDICAID PROVIDER

I ACCEPT MOST PRIVATE INSURANCE

( Schedule your consultation to determine if I am able to accept your insurance and to see if you have Behavioral Health Benefits)

I HAVE A SLIDING FEE SCALE ( MUST RECEIVE PREAPPROVAL)

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• Cancellations and missed sessions: Appointments are to be made directly with the therapist. Appointments that are not canceled at least 24 hours in advance will be charged full fee to the client. The payment for the missed or late session is to be made by credit card. cash or by cashapp  prior to the start of the following session. You, not your insurance company, will be responsible for the full fee payment of this session. Cancellation messages may be left with the answering service or via text 24 hours a day.

• I charge a prorated fee from the hourly charge if calls are more than once a week and more than 15 minutes.

 

HOSPITALIZATION:

 

All patients who require hospitalization will be referred to a hospital treatment team. 

 

COLLECTIONS:

 

 Any patient with an unpaid balance that is over 60 days will be scheduled for an appointment and seen only if the balance is paid in full.  Consequently, if you have a balance, you will pay for the current visit in addition to the past due balance.

 

I have read the financial policy as stated above and agree to abide by the terms outlined.

 

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SIGNATURE OF GUARANTOR and/or PATIENT                                   DATE

 

How would you prefer to be contacted? (Check all that apply)___phone__mail____email