This fee is for a 60-minute session for psychotherapy services for myself/child given Lisa Inoue LMSW PLLC non-participation with my insurance company, my being uninsured or my desire to not utilize my insurance benefit for my mental health treatment. In the event that I choose to use my insurance coverage and Lisa Inoue LMSW PLLC is a participating provider, I understand that I am responsible for payment of the fees designated by my insurance company which may include a co-pay. I understand that the out-of-pocket expense, per session that I may be responsible for may be an amount closer to that of the full session fee if I have a deductible and that I am responsible for payment of this amount.
I understand that it is my responsibility to verify coverage, learn what my co-pay (if applicable) is, and find out what limitations of coverage exist (e.g., deductible, session limits, pre-authorization requirements, etc.). I realize that some insurance companies contract out their mental health coverage to another company, e.g., Blue Cross Blue Shield may contract out their mental health coverage to Magellan. In such a case, I may be responsible for an out-of-network rate even though Ms. Inoue is in network for my main insurance. If the insurance company does not pay for a service, I will pay for that service.
I understand that if I am late for an appointment that the session will still end 60 minutes from the originally scheduled start time. I also understand that I am responsible for payment which corresponds to the entirety of the scheduled time and that I may be responsible for a payment in addition to my insurance co-payment if Lisa Inoue, LMSW, PLLC is not able to bill for the entirety of the originally scheduled time.
Sessions that significantly exceed 60 minutes will be prorated at the hourly rate set by insurance fee or private-fee arrangement. I understand that payment of the agreed upon fee, or insurance co-payment, will be made at the time of service unless other arrangements are made. I further understand that I am responsible for paying all balances not paid by my insurance company within 30 days, and I hereby agree to allow the release of basic information to a collection agency should I fail to pay any outstanding balances. I agree to pay any and all fees incurred by Lisa Inoue, LMSW PLLC that may be necessary to collect any unpaid balances after reasonable notification that I have an unpaid balance.
I understand that Lisa Inoue LMSW PLLC reserves the right to bill me at the prorated rate of $150/hour or per our private, reduced fee agreement should she need to participate in phone calls exceeding 15 minutes in length, with myself, my child or someone cooperating with myself or my child’s treatment.
I also understand that Lisa Inoue LMSW PLLC reserves the right to bill me at the prorated rate of $150/hour or per our private, reduced fee agreement for any paperwork that she may need to complete on my or my child’s behalf that cannot be completed within our session time.
I further understand that I am required to give 24-hour notice in order to cancel my psychotherapy appointment. I hereby agree to pay the fee equivalent to that fee which my therapist would be reimbursed had I kept my appointment for any appointments that I fail to cancel 24 hours in advance. An exception to the requirement to give 24 hours notice will be made the first time it occurs. If we reschedule for a date and time during the week of the cancelled session, per my therapist’s availability, there will be no cancellation fee charged. The missed appointment/late cancellation fee is due within seven days or at the next appointment, whichever is sooner. I understand that my insurance company will not pay for missed appointment or late cancellation charges.