Insurance Coverage and Billing: We are happy to bill your insurance company directly. It is your responsibility before your first visit to check your coverage for our mental health services, including any deductible, copay, or coinsurance. We may collect full payment for services at the time of visit until we have confirmation of your insurance coverage.
Miscellaneous Service Charges: Please be advised that therapist time spent on client-related professional services outside of the therapy session is not billable to insurance. Non-billable services will be charged to the client.
Confidentiality: There is legal and ethical protection for the information that you share with your therapist and it cannot be released without your written consent. This also covers our written record. There are also exceptions to privacy/confidentiality, which may include, but are not limited to when Networks, Inc. clinicians provide collegial case coverage and case consultation. Other exceptions to confidentiality that include but are not limited to: when there is reason to believe that you intend to harm yourself or another person; when a child, elder or disabled adult has been or might be abused or neglected; or if information is requested by court order.
Confidentiality and Insurance Companies: If you have benefits under a managed care plan including Medicaid and Medicare, Networks may be required to provide information related to your case to the managed care reviewer and your primary physician, in writing and verbally. Networks Inc. will follow these procedures unless otherwise notified by you in writing. I acknowledge the use of the Networks internal billing services to bill for those charges to be submitted to my insurance company. These claims may be submitted electronically. I acknowledge that Networks’ billing staff will be given a copy of my “Registration Form” in order to process these claims and/or to maintain a record of my account. If necessary, I authorize the Networks billing staff to contact my insurance company to check on claims submitted for payment for services.
Outside Billing: Networks utlizies an outside biller, Claims Connections, who the company has a legal confidentality BAA signed with.
Telehealth Practices/Virtual Communication: Telehealth will be delivered through a pre-approved platform, approved by HIPPA standards. Use of any other platform for clinical service delivery is strictly prohibited. In order to facilitate the billing and payment of services provided at Networks, Inc., email communication between the client and Networks, Inc. may be available. However, we currently do not have secure email capabilities. This means that any information sent via email cannot be guaranteed to be private.
Mental Health Emergencies: If you are having a mental health emergency, please call 911 or 988, go to your nearest Hospital Emergency Department or call crisis services at 1-802-488-7777.
Consent for Treatment: I voluntarily consent to clinical evaluation/ treatment for myself or my minor child. I understand that there are both benefits and risks involved with engaging in psychotherapy and/or psychiatric treatment that there are no guarantees about the outcome.
My signature below indicates that I have had an opportunity to ask and have my questions answered about the above information and I have read, understand and agree to abide by all of the above outlined terms.