May 12 2008
Fee, confidentiality and service agreement
Fee Policy, Confidentiality Statement, and Consent for Services
William Martin, LCSW
Thank you for your interest in my services as a clinical social worker. The following information provides some explanation about my work, fees, payment policies and confidentiality rules. Please read this, sign and give it back to me at our next session.
Payment Schedule
My regular fee is $140.00 per 50 minute session.
Payment is due at the time services are rendered.
Insurance Procedures
If you have medical insurance, it is important to understand that you are responsible understand your mental health benefits and to submit all claims. If you are unfamiliar with your mental health benefits, please call the customer service phone number on the back of your insurance card for more information. It is very important that you determine the following details:
1) Is there any managed care pre-certification needed?
2) Is William Martin, MSW, Licensed Clinical Social Worker (LCSW) an approved provider?
3) What is the calendar year maximum benefit for mental health services?
4) How many sessions per year are authorized?
5) Is there a per session fee limit?
6) Where are claims mailed and/or is electronic billing possible?
7) Is there a difference for in-network or out-of-network benefits?
It is important for you to understand that when you or I provide your insurance company with a claim, the claim will report the type of service, fees and payments and a mental health diagnosis. All of this information, including the diagnosis, becomes a part of your medical records. You will likely be asked by any potential insurance carrier for information related to any psychotherapy services you receive. Likewise, you may be asked to sign a confidentiality release by the insurance company to obtain any of your client records, including diagnostic information.
It is your responsibility to request claim information. Calling my voice mail is the easiest and most reliable way to make a request for the most recent claim. Once you make the request, I will provide the information as quickly as possible. Do not hesitate to follow-up with me if you do not receive the information promptly.
Some insurance companies, however, reimburse on a “schedule” that may be below the current standard. Depending on your insurance, you may be required to pay out of pocket the difference between my charges and their reimbursement.
I need to emphasize that my relationship is with you and not with your insurance company. All charges are your responsibility from the date the service is rendered.
HMOs and Managed Care Provider Networks
I am not a part of any HMO or managed care network. If you have this type of insurance coverage, I will be happy to refer you to colleagues who may accept such insurance or negotiate an acceptable payment for you to receive services from me.
Services Not Covered
Regardless of the nature of your third-party payer, some of the services you receive may not be covered under your mental health benefit. Responsibility for payment for those services rests with you. However, non-reimbursable services will be thoroughly discussed with you before they are provided, and you will have full opportunity to refuse such services and to consider alternatives.
Payment Methods
I accept cash, personal checks, and visa of master card credit cards. Returned checks will be subject to a minimum $6 charge, which will be added to your bill. Balances older than 45 days will be subject to interest charges of 18% per month. Unpaid balances older than 90 days and in excess of $500 will be the basis for terminating service. In this unfortunate event, I will make every effort to help you locate alternative affordable care; however, I will be unable to continue to work with you in the face of financial default.
(If applicable, also note that the law allows the referral of unpaid bills to a collection agency or the utilization of small-claims court procedures. Note that this is not the preferred course of action, but may become necessary if the problem of a delinquent account cannot be resolved otherwise.)
Charges for Late and Canceled Appointments
I require 24 hours advance notification if you are not able to keep a scheduled appointment, including group therapy sessions. This notice permits me to offer that time to someone else. If you have given 24 hours notice, you will not be charged for the appointment. However, if you break your appointment and do not call this office within 24 hours, you will be charged for the session.
I understand that there may be occasional emergencies when you will not be able to keep your appointment and also will not be able to notify us within 24 hours, for example serious illnesses and/or accidents. I will take these circumstances into account.
Charges for broken appointments and appointments canceled without 24 hours’ notice cannot be billed to your third-party payer. You will be personally responsible, therefore, for the full amount of the session.
If for some reason, I am unable to keep our appointment and am unable to notify you with enough advance notice to prevent your arrival for the session, there will be no charge for the next scheduled session.
Charges for Home Visits, Telephone Contacts
Emergency Appointments, and Collateral Contacts
Occasionally, it is necessary for a session to be held elsewhere, ex. hospital, school, court, other agency or center . My out-of-office fee is $140 per hour, from my office door back to my office door. Thus, a one-hour session of any type and travel time of 30 minutes each way would result in a charge of two hours.
Brief telephone calls in which you advise me of a schedule change or ask for a specific piece of information are not charged. If the duration of the call is less than five minutes, you will not be charged. If the situation requires telephone consultation that exceeds five minutes, the fee for such service will be pro-rated at my regular $140 per hour fee.
If your need is more urgent and complex and it cannot be postponed until a scheduled appointment, an immediate emergency appointment will be arranged and billed at usual fee.
If, with your permission, I contact other people on your behalf—such as family members, teachers, or other health care professionals—and consult with them in person or by telephone, then the above fees for scheduled in-office and out-of-office sessions, as well as telephone contacts, will apply.
Confidentiality
All of our sessions will be confidential unless there is any concern of harm to yourself or others. This includes the possibility of a child under the age of 18 being abused, physically, sexually or physically. In the event that there is a risk of harm to someone, it is my legal and ethical responsibility to take immediate action to protect that person. This action could include calling 911 or having a person hospitalized for their own or some other person’s protection.
Fee Agreement
By signing below I am indicating that I have read the above statements on fees and payment policies. I have discussed these conditions with William Martin, LCSW and have had the opportunity to ask any questions. My questions have been answered to my satisfaction. I understand and agree to meet my financial responsibilities in receiving treatment and services in this practice setting.
Client name (please print)
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Witness/William Martin, LCSW
Signature
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