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  • Welcome and thank you for seeking out information about the NeuroScience & TMS Treatment Centers.  

    As you begin this process, read this letter. You will be asked to sign below stating that you have read it.   

    When you are selecting a clinician to see in the office, note that our clinicians are in different insurance networks. We are presently trying to get all clinicians on the same contracts.  

    Verify below in the appointment selection section and also with the office staff who books your appointment.  Make sure you are scheduled with the clinician with which you wish to be booked and that you understand if they are out-of-network or in-network with your insurance company.  

    You can use out-of-network coverage benefits (if your insurance allows) with other insurance policies by requesting a statement of service and your bill. 

    We are NOT In-network with Medicare nor TNCare.    

    We cannot bill for services with Medicare nor TNCare. Please Note that BCBS, Anthem, United, Optum, and Cigna manage some Medicare policies: if your policy is a Medicare or Medicaid policy, managed by one of these companies, then we are NOT in your network. 

    The therapists associated with the clinic are NOT on any insurance panels, they are "out of network" with any insurance companies and charge private rates.  

         _______________________________________________

     This is the beginning of the 3 Step Enrollment process to become a patient.  In our clinic, we care for patients age 14 and up. 

    The application should take 10-20 minutes depending on your personal speed with these types of electronic forms.  If you don't have time to finish you can save the form and return it later to complete it by pressing "SAVE and CONTINUE Later."

    STEP 1: Complete this private, HIPAA-compliant questionnaire and select a service.  Complete the Insurance Section* so that we can file in-network claims & so you understand what and how your insurance will pay. 

    *If you want us to submit the claim to your insurance, you will need an electronic copy/photo of the subscriber's insurance card (front & back) while completing this form. You will also need an electronic copy/photo of your driver's license to complete the application. 

    STEP 2:  Read and agree to all office policies AND Pay the new appointment deposit** 

    **The new appointment deposit covers part of the fee for the potential of a Missed Appointment, or Late Cancellation as our clinicians set aside significant time for the new patient appointment. Insurance does not cover missed appointments or Late Cancellations, see the policies below. If you come to your scheduled appointment and your insurance covers your visit fees, we will reimburse (or credit your account) for any amount which you may have overpaid.

    STEP 3:  Prior to your initial appointment, you will receive emails to complete a Medical History questionnaire, assessments, and releases, these are essential to your initial visit.  If you don't complete the Medical History you will be asked to do it at the first appointment.  

          ______________________________________________ 

     We look forward to helping you with the process of reaching wellness.

    If you have questions about the process, email Brogan Allen, support@hopeforyourbrain.com.

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  • Step 1: Complete Questionnaire & Select Service

  • Minor or Ward Consent Form

    for patients who are under 18 years old or who have a legal guardian. SKIP this section if it is not relevant
  • The Custodial Parent or Legal Guardian should REVIEW AND SIGN this Consent to Treat Minor IF Patient is under 18 years of age or has a legal guardian. 

    If the patient is under the age of eighteen or unable to consent to treatment, a legal custodian of the Patient will be required to authorize and consent for the initial evaluation and on-going treatment on behalf of the Patient.

    I voluntarily consent that my child, or ward, will participate in a mental health evaluation (e.g. psychological or psychiatric) and/or treatment by staff from the NeuroScience and TMS Treatment Center. The evaluation and treatment will be made by a licensed mental health clinician (a psychotherapist, psychologist, psychiatric nurse practitioner, psychiatrist, or licensed therapist). I understand that following the evaluation and/or treatment, complete and accurate information may be provided concerning each of the following areas:

    1. The benefits of the proposed treatment 
    2. Alternative treatment modes and services
    3. The manner in which treatment will be administered
    4. Expected side effects from the treatment and/or the risks of side effects from medications (when applicable).
    5. Probable consequences of not receiving treatment 
    6. Expectations regarding the length and frequency of treatment

    It may be beneficial to my child, or ward, as well as the referring professional, to understand the nature and cause of any difficulties affecting my child’s, or ward’s, daily functioning, so that appropriate recommendations and treatments may be offered. Uses of this evaluation include diagnosis, evaluation of recovery or treatment, estimating prognosis, and education and rehabilitation planning. As a parent or guardian of the patient seeking evaluation and treatment, I may have useful information for the professionals doing the evaluation and ongoing treatment, because of this fact, please disclose all information which can be helpful to the treatment team at any point in the care process. Information can be given verbally, or in written communication.

    Treatment will hopefully give benefits, which may include improved cognitive or academic performance, emotional and physical health status, quality of life, and awareness of strengths and limitations.

    Fees are based on the length or type of the evaluation or treatment, which are determined by the nature of the service. As the parent or guardian of the patient, I will be responsible for charges. Fees are available to me upon request and may be referenced in the new patient packet.

    Information from my child’s, or ward’s, evaluation and/or treatment is contained in a confidential medical record at the NeuroScience and TMS Treatment Center, and I consent to its use by staff for the purpose of continuity of my child’s, or ward’s, care. Per Tennessee mental health law, the information provided will be kept confidential with the following exceptions: 1) if my child, or ward, is deemed to present a danger to himself/herself or others; 2) if concerns about possible abuse or neglect arise, or 3) if a court order is issued to obtain records.

    I have the right to withdraw my consent for evaluation and/or treatment of my child, or my ward at any time by providing a written request to the treating clinician. I have read and understood the above, have had an opportunity to ask questions about this information, and I consent to the evaluation and treatment of my child or my ward. I also attest that I am the legal guardian and have the right to consent for the treatment of this child or ward. I understand that I have the right to ask questions of my child’s, or my ward’s service Clinician about the above information at any time.

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  • Give us some information about you (the patient) in the following questions.

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  • So we may allow the proper amount of time for your care, Please Review and then select one or more of the options in the section that follows. 

    The prices shown are Private rates (out-of-network rates); in-network rates will vary depending on the clinician's participation with your insurance, the covered services allowed, your deductible, your co-insurance, and your copayments. 

    • Evaluation for Adults 18 and older- Jonathan Becker, Psychiatrist (60-90 min First appt: $495.  Follow-up: 15-20 min = $150, 20-30min = $250, 50-60min = $350). Currently in-network with BCBS & Anthem and Cigna.  Others are out-of-network now, he has pending contracts for UnitedHealthcare/OPTUM & Aetna.

     

    • Evaluation for Adults 18 and older- Mary Strayhorn Phillips, Psych Nurse Practitioner (60-90 min first appt: $395.  Follow-up: 20-30 min=$120, 50min =$200). Currently in-network with BCBS, Anthem, Cigna, and United Healthcare. Other insurance is out-of-network; she does have a pending contract with Aetna.

     

    • Evaluation for Adolescents and Adults, Ages 14 and up - Susan Swanson-Moore, Psych Nurse Practitioner (60-90 min First appt: $395/Follow-up: 20-30 min=$120, 50min =$200). Currently in-network with BCBS, Anthem, Cigna, and United Healthcare. Other insurance is out-of-network; she does have a pending contract with Aetna.

     

    • Therapist Only - Evaluation - Ali T. Self, LMSW (up to 90min Initial $250/ 50-60min, Follow-up $135). Out-of-network with all insurance; Not in-network with any insurance.

     

    • Therapist Only - Evaluation - Lauren Valencia LCSW (up to 90min Initial $250, Follow-up $135). Out-of-network with all insurance; Not in-network with any insurance.

     

    • TMS or Esketamine Treatment Consultation with Michelle Cochran, MD, DFAPA; (total time 60-90 min, $350)** THIS APPOINTMENT WILL BE ACCOMPANIED BY A PRE-SCREENING APPOINTMENT with Care Coordinator at no charge.  Currently are in-network with BCBS, Anthem, Cigna, and Optum, United Healthcare. Other insurance is out-of-network; There is a pending contract with Aetna, and other insurance offers single case agreements.  

     

    • TMS or Esketamine Treatment Consultation with Jonathan Becker, DO; (total time 60-90 min, $350)** THIS APPOINTMENT WILL BE ACCOMPANIED BY A PRE-SCREENING APPOINTMENT with Care Coordinator at no charge. Currently in-network with BCBS & Anthem; Others are out-of-network now, he has pending contracts for Cigna, UnitedHealthcare/OPTUM & Aetna.  
  • If you would you like a FREE Screening Consultation with the Care Coordinator, to see if TMS or Esketamine is right for you, call, 615-348-8200 - No appointment, and no deposit is needed for this Screening visit.

  • STEP 2: Complete the Insurance Section

    Our psychiatric Nurse Practitioners are in-network with many insurances at NeuroScience & TMS Treatment Centers (unfortunately therapist is not in-network). If you have other insurance you may have out-of-network benefits. You will need to send a copy of the FRONT/BACK of the insurance card and a copy of the DRIVER's LICENSE. If there is no insurance write, "NONE"
  • Please attach a copy of the FRONT & BACK of your insurance card & a copy of your driver's license with this form.

    If you lack the technology to do this, please email support@hopeforyourbrain.com or call 615-224-9800, and we can discuss other ways you could send or drop off your information.
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  • Health Insurance does not cover all potential fees. If we are filing insurance for in-network charges, your insurance requires you to complete the following three (3) acknowledgments.

    READ all three (3) statements & sign below to acknowledge that you have read and understood your responsibilities. If you are paying privately or are using insurance as an out-of-network service, then you are not required to sign below. If this is the case, write Not Applicable in the signature line)

  • 1) ACKNOWLEDGMENT OF NON-COVERED CHARGES

    Re (Identification of Prescribed Service): Charges for a Virtual visit, phone call or phone call session which is outside office hours (Emergent or Urgent calls)
  • Most insurance companies are covering virtual (phone & video) sessions presently. Legally you must be in Tennessee to receive services from our clinicians.  

    Even though these visits are generally covered, I have been informed that my health care benefits insurer or administrator may determine that the above-referenced service(s) may be an Investigational Service, Cosmetic, may not be a Covered Service or may not be Medically Necessary or Medically Appropriate as those terms are defined in my Member health care benefits plan. Therefore, the service would be excluded from coverage by my health care benefits plan. My provider has also informed me about alternative treatments, if any, that may be covered by my insurance company.

    I understand that my provider may request that my insurance reconsider that determination by presenting evidence that the referenced service(s) is not an Investigational Service, is a Covered Service or the service is considered to be Medically Necessary or Medically Appropriate. I also understand that I have the right to request reconsideration of that determination, as described in the Member grievance section of my health care benefits plan, either before or after receiving the service(s) I have been informed that the potential costs of the referenced service(s) will be approximately $100 per 10 minutes for a phone call or video session when completed emergently or urgently outside a clinician's scheduled hours. I understand that, if I elect to receive the service(s) and my insurance company determines that the service(s) 1) is an Investigational Service, 2) is not a Covered Service or 3) the service is not considered to be Medically Necessary or Medically Appropriate, I will be responsible to pay for all costs associated with the service(s), including, but not limited to, practitioner costs, facility costs, ancillary charges, and any other related expenses. I acknowledge that my insurance may not pay for the service(s

    In the event of multiple procedures, this form is valid only for one (1) unit of the prescribed service(s), unless specifically provided for otherwise.

    This form shall be active while I am under the care of a clinician at the NeuroScience & TMS Treatment Centers.

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  • 2) ACKNOWLEDGMENT OF NON-COVERED CHARGES

    Re (Identification of Prescribed Service): Charges for Missed Appointments or Late Cancellations (failure to keep a scheduled appointment or notify us to cancel with 3 business days' notice).
  • I have been informed that my health care benefits insurer or administrator may determine that the above-referenced service(s) may be an Investigational Service, Cosmetic, may not be a Covered Service or may not be Medically Necessary or Medically Appropriate as those terms are defined in my Member health care benefits plan. Therefore, the service would be excluded from coverage by my health care benefits plan. My provider has also informed me about alternative treatments, if any, that may be covered by my insurance coverage.

    I understand that my provider may request that my insurance company reconsider that determination by presenting evidence that the referenced service(s) is not an Investigational Service, is a Covered Service or the service is considered to be Medically Necessary or Medically Appropriate. I also understand that I have the right to request reconsideration of that determination, as described in the Member grievance section of my health care benefits plan, either before or after receiving the service(s),

    I have been informed that the potential costs of the referenced service(s) will be approximately $120 for a 20-30 minute follow-up session with a Nurse Practitioner, or $200 for an hour session with a Nurse Practitioner, or $250 for a  30min  follow up,  or $350 for an hour follow-up session with a Medical Doctor. I understand that, if I elect to receive the service(s) and my insurance determines that the service(s) is an Investigational Service, is not a Covered Service or the service is not considered to be Medically Necessary or Medically Appropriate, I will be responsible to pay for all costs associated with the service(s), including, but not limited to, practitioner costs, facility costs, ancillary charges, and any other related expenses. I acknowledge that my insurance may not pay for the service(s

    In the event of multiple procedures, this form is valid only for one (1) unit of the prescribed service(s), unless specifically provided for otherwise.

    This form shall be active while I am under the care of a clinician at the NeuroScience & TMS Treatment Centers.

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  • 3) ACKNOWLEDGMENT OF NON-COVERED CHARGES

    Re (Identification of Prescribed Service):  Clinical work outside of session including electronic Prescription Refills and other related work either electronic, email, and/or paperwork.
  • I have been informed that my health care benefits insurer or administrator may determine that the above-referenced service(s) may be an Investigational Service, Cosmetic, may not be a Covered Service or may not be Medically Necessary or Medically Appropriate as those terms are defined in my Member health care benefits plan with my insurance. Therefore, the service would be excluded from coverage by my health care benefits plan. My provider has also informed me about alternative treatments, if any, that may be covered by my insurance.

    I understand that my provider may request that my insurance reconsider that determination by presenting evidence that the referenced service(s) is not an Investigational Service, is a Covered Service or the service is considered to be Medically Necessary or Medically Appropriate. I also understand that I have the right to request a reconsideration of that determination, as described in the Member grievance section of my health care benefits plan, either before or after receiving the service(s). 

    I have been informed that the potential costs of the referenced service(s) will be approximately $30 for a prescription refill outside of a session, or other related clinical work prorated accordingly to the length of time at $40 per 10 minutes. I understand that, if I elect to receive the service(s) and my insurance determines that the service(s) is an Investigational Service, is not a Covered Service or the service is not considered to be Medically Necessary or Medically Appropriate, I will be responsible to pay for all costs associated with the service(s), including, but not limited to, practitioner costs, facility costs, ancillary charges, and any other related expenses. I acknowledge that my insurance may not pay for the service(s).

    In the event of multiple procedures, this form is valid only for one (1) unit of the prescribed service(s), unless specifically provided for otherwise.

    This form shall be active while I am under the care of a clinician at the NeuroScience & TMS Treatment Centers.  

     

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  • STEP 3: REVIEW POLICIES & PAY THE DEPOSIT Please review all office policies on our website (Privacy Policies, General Office Policies, and Insurance & Payment Policies).

    Please read and check that you understand each of the individual policies on www.hopeforyourbrain.com. If questions, email us, support@hopeforyourbrain.com.
  • The policies, below, are highlighted for emphasis: 

     

    ****Read ALL the Policies (Privacy, General Office, and Insurance & Payment Policies), on the website, www.hopeforyourbrain.com, then sign below.****

     

    Late Cancellation/Missed Appointment Policy

    Notification must be received by 4:00 pm CDT, three (3) business days before the scheduled appointment in order to avoid charges.

    If you have to cancel or reschedule my new patient appointment, you must give three (3) business days' notice prior to the date of the appointment in order to receive a full refund. A large block of time is booked for the new appointment, and we must have a 72-hour (three business-day) notice in order to potentially reschedule the time. If you cancel the new patient psychiatric appointment or miss this appointment, you will be responsible for the full-fee ($395) and this can not be billed to insurance. We will use your deposit for part of this late cancellation/missed appointment but you will still owe $220, (total charge $395 - deposit $175 = Remaining balance of $220).

    The initial therapy appointments are $250 and are not in-network charges.  We require a full deposit for new therapy appointments.  If you cancel the new therapy appointment with less than three business days' notice or miss this appointment, you will be responsible for the full-fee ($250). We will use your deposit for the late cancellation or missed appointment.  

    For all follow-up appointments, we also have a 72-hour cancellation policy. If you miss an appointment OR do not cancel with a three (3) business-day notice, you will be obligated to pay the full fee of the service.  For example, the Late cancellation or missed Nurse Practitioner session/30-minute appointment would cost $120/a late cancel or missed Nurse Practitioner session/30-minute appointment would cost $200.

    Again, Late Cancellations and Missed Appointment fees are not covered by insurance.

     

    Prescription Refill Policy

    The policy in the office is to refill all medication within an appointment, and because of this we generally, do not prescribe medication outside office visits.

    Medication refills are handled during office hours, during scheduled appointments, when an assessment can be made of the patient.  We refill medications only for patients currently under our care.

    If you are prescribed medication, you will be given enough medication to cover you until your next scheduled appointment. If you have to cancel please reschedule quickly to avoid running out of medication. Contact us directly if you need a refill of prescribed medication, and allow 72 hours for refills to be sent.

    Prescription refills outside of an office visit will be charged $30. This fee is not billable to your insurance.

    If your appointment is rescheduled because of unforeseen circumstances, on our part, there will not be a charge.

     

    Payment of Charges Policy

    All charges must be paid at the time of service. The office staff will collect for the booked amount of time with the Clinician (or co-pay and deductible if applicable).

    You are agreeing to allow Neuroscience & TMS Treatment Centers (NS-TMS) to charge the credit card on file for any fees due that are outstanding following the appointment or outside of an appointment.

    The following are a few common examples of when this might happen:

    • If you have insurance coverage for your appointments and we incorrectly collected a lower estimated co-pay, co-insurance, and/or deductible, and then later receive an Explanation of Benefits (EOB) from your insurance showing that we did not collect enough money from you, then we will notify you and charge the balance to your card on file.

    • If your appointment goes beyond the originally booked time, then the clinician will bill for the additional amount of time in the session, and this could mean that you might have a larger charge than you paid when you arrived for the appointment.

    • The clinicians charge their hourly rate for any service on your behalf (letter writing, review of medical records, calls to outside therapists/or clinicians caring or you, review of labs/tests, completing special insurance forms, emergency call after hours, refills outside of your appointment, late cancellations/no-show charges, etc.).

    Likewise, if we overcharge you, we will immediately apply the credit to your account. If you prefer, notify us and we can refund the charge.

  • By signing below, I am acknowledging that I have read all of the policies on the NeuroScience & TMS Treatment Centers website.

    I agree to my cardholder policy and I authorize the deposit selected by me, as well as, all outstanding fees, non-covered fees, and late cancellations or missed appointment fees to be charged to my credit card as explained in the Insurance & Payment policies and the General Office policies.

    I have read & agreed to all policies of the NeuroScience & TMS Treatment Centers (Privacy, General Office, and Insurance & Payment) and any and all of those policies that may be amended and published on www.HopeForYourBrain.com.

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