Consent to Contact Insurance Provider
I hereby give my consent for Westside Behavior Therapy to bill my/my child’s insurance carrier for the services rendered to my child by Westside Behavior Therapy.
I understand that my express consent is required to release any health care information relating to assessment and treatment. I hereby give my consent for Westside Behavior Therapy to release medical and other relevant information to our insurance carrier as requested by my/our insurance carrier to process medical billings.
I further authorize my insurance company to pay from the proceeds of benefits of any recovery or insurance payments in my case, directly to the provider(s) of this office, for their professional services rendered.
Responsible Party Financial Obligation
Insurance
Insurance is a contract between you and your insurance company. In most cases, Westside is NOT a party of this contract. However, as a courtesy to you, we will bill your primary insurance company. To properly bill your insurance company, we require that you disclose all insurance information including primary and secondary insurance, as well as any change of insurance information. Failure to provide complete insurance information may result in patient responsibility for the entire bill. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and benefits.
If your insurance company is not contracted with us, you agree to pay any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance. If we are out of network for your insurance company and your insurance pays you directly, you are responsible for payment and agree to forward the payment to us immediately.
Co-payments, Coinsurance, Deductibles, Outstanding Balances, and Fees
Deductible, co-pay, and coinsurance amounts are part of your insurance contract with your insurance company. Failure on our part to collect coinsurance, co-payments, and deductibles from clients can be considered fraud and is in violation of our contractual agreements with payors. All patient responsibility, outstanding balances, and fees for services not covered by your insurance policy are due on the date listed on your invoice(s). For any questions regarding coverage for any services/treatments, we encourage you to contact your insurance carrier to review costs. As a convenience, we accept Visa and Mastercard, debit cards, checks, and cash.
Claim Submission
Westside Behavior Therapy submits claims for services on a weekly basis. Insurance processing times may vary. Invoices are generated as claims are processed and are available to view and pay in the client portal. Invoices include a breakdown of the date of service, service type, charges, and patient responsibility. Please check your insurance Explanation of Benefits (EOB) for detailed processing and payment information.
Proof of Insurance and Coverage Changes
All clients must have updated insurance information on file. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of the claim. If your insurance changes, please notify us before your next session so we can make the appropriate changes to help you receive your maximum benefits.
Self-Pay
Clients without insurance coverage will be required to pay for all services at the time they are provided. Westside may offer a discounted rate to self-pay clients. Please contact the Director for information and arrangements.
Consent Orders
Westside Behavior Therapy is not a party to your child support consent order or divorce decree. The financial responsibility for the minor client rests with the adult signing this disclosure.
Nonpayment
If you have financial hardship or are unable to pay your bill in its entirety by the due date, please contact the Director to discuss payment options.
Late Payment
If your invoice is 30 days past due, your account will incur a $35 late fee per month for each past due invoice. Partial payments will not be accepted for past due amounts. Please be aware that if a balance remains unpaid, your child may be discharged from services and your account referred to a collection agency. All third-party costs and fees will be your responsibility, including reasonable attorney fees and court costs.
Returned Checks
A $35.00 fee will be charged on all returned checks.
Transfer of Care
When transferring care to another provider, we will require you to close out any balances due. Charges for printed medical records will be calculated according to state rules and regulations. Payment is due at the time the records request is made.
Sessions with Supervisors and Therapists are reserved specifically for your child.
· Morning Session begins at 8:00am and ends at 11:50 am
· Afternoon Session begins at 1:00pm and ends at 4:50 pm
Late pick up/drop off
Your child’s session with their therapist and Supervisor are scheduled and reserved specifically for your child. Please arrive before scheduled start time and arrive at the scheduled session end time. Late fees (see schedule below) will incur for late drop off or pick up.
Ethical guidelines and insurance billing protocols require that healthcare providers begin and end reserved sessions based on specific timeframes. Please allow adequate time and planning to assure that your child’s reserved clinical session can begin and end on-time according to their treatment schedule.
Westside requires a Monday through Friday clinical treatment schedule for all clients.
· Morning Session begins at 8:00am and ends at 11:50 am
· Afternoon Session begins at 1:00pm and ends at 4:50 pm
· Late Fee may apply for pick-ups after session end time.
· At Westside’s discretion, excessive tardiness (either drop-off or pick-up) may result in client discharge.
No Show/Cancellation/Unexcused Absence without 24-hour notice
Missed sessions represent a cost to us, to you, and to other clients who could have been accommodated. Sessions missed or not canceled at least 24 hours before the session time may result in a $75.00 fee which is not covered by insurance. Sessions may be canceled by sending an email or text to your case supervisor. Please help us serve you better by keeping your scheduled session. Excessive absences interfere with your child’s treatment and therefore may lead to client dismissal.
Extended Cancellations
Excessive or extended cancellations interfere with your child’s treatment and may impact progress. Under specific circumstances, Westside may hold a child’s therapy spot for up to five (5) consecutive canceled treatment days. Six (6) or more consecutive canceled sessions will require review by Westside’s Director. Under this circumstance, a return to a regular session schedule or client dismissal is at Westside’s discretion.
Appropriate Fees may be imposed in the following circumstances:
· Session cancellations without 24 hours’ notice: $75.00
· Unexcused absence (not illness-related): $75.00
· No show: $75.00
· Returned Checks: $35.00
· Late Payment charge: $35.00
· Printed records requests will incur an appropriate fee, either flat rate or per page. Requests require 30 days for fulfillment.
· Late drop off or pick-up fee: $1.00 per minute after assigned time. A 5-minute grace period applies. At Director’s discretion, Westside may excuse three (3) tardy instances per year.
Westside Behavior Therapy reserves the right to dismiss any client who consistently fails to meet the requirements and obligations of this policy. By signing below, I understand and agree to the terms of Westside’s Consent to Contact Insurance Provider & Responsible Party Financial Obligation.