Thank you for choosing Wolff Child Psychology, a private practice owned by Dr. Brian Wolff, Ph.D. This document is an agreement about the fees you have agreed to for our services. If you have questions, please contact Dr. Brian Wolff at (303) 500-3407 or email@example.com.
Wolff Child Psychology accepts cash, check, or credit card payments. There will be a $25.00 charge for checks drawn on insufficient funds. We reserve the right to use a collection agency to collect fees that are more than 90 days past due, unless we have mutually agreed on an alternative payment plan. Any fees incurred by Wolff Child Psychology from a collection agency will be charged to your account.
Our standard billing rate for a 60-minute therapy session is $200 unless other arrangements have been made. Billing arrangements will be made directly with Dr. Brian Wolff. Please contact us at least 24 hours ahead of time if you need to cancel a therapy appointment. Without this notice, you may be charged in full for that appointment. Note that if you arrive late to your appointment, you will be charged your full session fee and the appointment will end at the previously agreed upon time. If a Medicaid plan covers the services provided to the Client, you will only be charged for the amount of time the Client is seen by a therapist if the Client is late, and you will not be charged for missed or late cancelled appointments. Wolff Child Psychology reserves the right to discharge a Client who is repetitively late and/or misses or cancels appointments in an untimely manner.
Wolff Child Psychology bills at the standard hourly consultation rate of $200/hour for “collateral” clinical work outside of therapy sessions, including:
· Face-to-face time spent with clients or parents outside of regularly scheduled therapy sessions.
· Clinically-oriented phone calls with clients, parents, teachers, or other providers.
· Writing e-mails to summarize treatment sessions for clients or parents.
· Attendance at school meetings or other professional settings.
· Completing documentation needed for other providers (e.g., applications for other services)
If the services provided to Client are covered by Medicaid, you will only be charged for the above services to the extent such charges are allowed by Client’s Medicaid plan.
Client’s Financial Responsibilities
· You agree that you are ultimately responsible for the payment of Client’s evaluation, treatment and care. Payment is due at the time of service unless alternative arrangements have been made as described in this form.
· Wolff Child Psychology contracts with and accepts payment from a limited number of insurance providers and Medicaid plans. If Wolff Child Psychology is contracted with your insurance provider or Medicaid plan, we will attempt to confirm your eligibility and obtain any required pre-authorization, and will communicate with you regarding whether the service(s) will be covered by your insurance provider. If a service(s) is covered by your insurance provider, you understand and agree that you will be responsible for the payment of any amount allocated by your insurance provider to patient responsibility, including applicable copays, coinsurance, deductibles, and for the payment of all other services that are not covered by your insurance provider. You understand and agree that you are responsible for providing us with correct and current information about your insurance, and that you will be responsible for any charges incurred if the information provided is not correct or up to date.
· If Wolff Child Psychology is not contracted with your insurance carrier or health plan, you understand and agree that we will not directly bill and will not accept payment from your insurance provider. Instead, you will be expected to pay for all services rendered at the time of service, unless prior alternative arrangements have been made as described in this form. At your written request, we will provide you with a detailed receipt that you can submit to your insurance company. This receipt will have all relevant information about diagnosis(es) and billing code(s). Some insurance companies reimburse clients for services and some do not. Some conditions for which people seek evaluation or psychological services do not qualify for reimbursement. If a qualifying diagnosis is appropriate in your case, we will inform you of the diagnosis we plan to render. Please be aware that any diagnosis you choose to share with your insurance company will become part of your insurance record. If you choose to request reimbursement from your insurance provider, please request they reimburse you directly and do not assign any insurance payment to Wolff Child Psychology. If you have any questions about whether Wolff Child Psychology is contracted with your insurance provider, please contact Dr. Brian Wolff at firstname.lastname@example.org.
Charges for Services Related to Legal Matters
Therapy provided by Wolff Child Psychology is not intended for use in any legal matter. In the event that you become involved in a legal matter during or after the time you receive therapy or other clinical services from Wolff Child Psychology, you agree to pay $300 per hour for all time spent by a Wolff Child Psychology therapist on the legal matter, including but not limited to: responding to subpoenas issued by any party involved in the legal matter, preparation related to the legal matter, phone calls, time travel to and from hearings or depositions, time testifying, time spent waiting to be called for testimony, and any other time spent by Wolff Child Psychology related to the legal matter.
By signing below, you understand that you are ultimately responsible for payment for the services Client receives at Wolff Child Psychology, regardless of any health insurance coverage. You have had the opportunity to review this Fee Agreement Form in its entirety and to ask questions. Any questions have been answered to your satisfaction. You consent and agree to the aforementioned policies of Wolff Child Psychology.