Thank you for choosing Pacific Mind Health. Please review this Fee Agreement and Financial Policy (the “Agreement and Policy”), which describes our schedule of fees for services, charges not covered by insurance, and additional fees. Please be sure you understand the policies regarding cancellations, missed appointments, methods of payment, insurance reimbursement, and past due accounts. If you have any questions about anything, please ask our administrative staff prior to signing this Agreement and Policy.
Our service rates and corresponding health insurance billing codes (numbers starting with ‘90’ refer to mental health services) this is not a comprehensive list and reflects the most common services provided by our staff. Additional codes may be used by your provider as deemed appropriate. Note: If your insurance pays for the appointments, your financial responsibility will be for the copayment, deductibles, and co-insurance for your appointment and rates will be as per contracted agreement with your insurance provider.
● Initial Consultation Individual $350.00
● Follow-up evaluation $175.00
● Therapy session $150.00
● Medical Records Requests $25.00 per request
● Phone Consultations (11-60 min.) $100.00 (prorated per 15 min.
●Fee for forms: $100 per form (documentation of treatment, employer treatment, and general treatment letters) *Emotional Support Animal certification: $150
Due to the time-intensive nature of consultations our office requires a 24-hour notice for patients to cancel a scheduled appointment. Under such a policy, the patient who fails to give appropriate notice for canceling an appointment will be responsible for a late cancellation or a no show fee.
Our office provides courtesy reminder calls to confirm all appointments before your scheduled time. Providing the required notice gives us the opportunity to schedule patients from our waiting list in the event your appointment is rescheduled or canceled.
**Note: Courtesy calls are just that, a courtesy. Not receiving a reminder call does not change the no show/late cancellation policy. Your credit card on file will be charged on the day of the missed appointment.
Our Late Cancellation/No Show Fees and Policy is as follows:
New Patient Appointments 1 Business Day (24 Hours) $150.00
Follow Up Appointments 1 Business Day (24 Hours) $75.00
Therapy Visits 1 Business Day (24 Hours) $125.00
If you are unable to keep an appointment because of a sudden illness or an unexpected personal emergency, notify our office at (562) 279-0180 or email our office at email@example.com as soon as you know you will not be able to attend your appointment.
The missed appointment fees are charges your insurance company is not responsible for and will not pay for; they are your financial obligation.
If you are requesting to waive your fee for a late cancellation/missed appointment because you were ill, we will require a physician’s note or documentation for the request to be considered.
Patients who fail to pay the no show fees will not be allowed to schedule future appointments until the fee is paid or payment arrangements are made. Multiple late cancellations or no shows will result in dismissal from our practice.
We are committed to helping you with your mental and behavioral needs.
● Past-due accounts – over 30 days $25.00 per month
Disability Forms Processing Policy
Due to the high volume of work and time that is needed to complete the disability forms, we have the following policy to assist in rapid processing of the important forms.
All disability, accommodation letters, any other general form requests that are processed will take 3-5 business days from the date received to complete, mail, or enter claim information into the state disability portal.
Paperwork cannot be processed unless you have completed all portions of the documents that are to be filled out by the patient. All signature areas must be completed.
A copy of the forms will be uploaded to your chart after the healthcare provider has signed the forms and it will remain a part of your permanent record.
New patients requesting state disability forms, life insurance forms, private insurance disability forms, and extended work absence or leave forms will require a $500.00 processing fee for the initial forms and $250.00 for the extension or subsequent forms. If you are an existing patient and your provider determines you will need disability/extended leave forms completed it will require a $250.00 processing fee for the initial forms and $125.00 for the extension or subsequent forms. Please be advised that Pacific Mind Health reserves the right to determine if a short-term disability is medically appropriate.
If you are on disability or leave you will be required to schedule weekly medical management and therapy appointments.
Paperwork will not be processed without payment in advance. We accept credit cards and checks. Please make checks payable to Pacific Mind Health. The insurance companies do not reimburse our healthcare providers for administrative functions; therefore, you shall be responsible for payment for disability forms processing.
We appreciate your assistance in completing your portion of the forms. This policy is to better serve you, our patient. Please sign and acknowledge that you read and understand this information. If you have any questions or concerns, please feel free to contact our office.
You will be expected to pay for either each session in full, or your insurance co-payment at the time of services. Accepted methods of payment are checks or credit cards.
Pacific Mind Health accepts insurance plans from a variety of providers. If you are using insurance or employee assistance provider to pay for our services, then we will:
(1) Expect and accept payment of your copayment amount at the time of service;
(2) File your claim with the insurance provider;
(3) Receive payment from your insurance provider;
(4). Expect that you will pay your portion due of copay, co-insurance, deductible, or fee difference at the time of your appointment..
Pacific Mind Health files insurance as a courtesy to you, and that you (not your insurance company) are ultimately responsible for your bill. If you insurance company denies a claim filed on your behalf, then you are responsible to pay Pacific Mind Health for the difference between the standard rate and the amount previously paid as copay unless approved otherwise by owners of the Pacific Mind Health.
If your insurance status changes - you must present your new insurance card/information at or prior to the time of your next appointment, or you may be responsible for the full cost of the appointment.
I agree to:
(1) Allow Pacific Mind Health to bill my insurance directly for services;
(2) Give Pacific Mind Health permission to release any information the insurance company may require in order to process payment; appoint Pacific Mind Health as my authorized representative to act for me in obtaining payment;
(3) assign all of my rights to claims and payment by my insurance to Pacific Mind Health;
(4) agree to assist with the claims process as required by Pacific Mind Health or my insurance provider. I understand that if my insurance plan requires that I meet a deductible amount prior to coverage by insurance, I will be responsible for the full session fee until the required deductible amount has been met. I acknowledge that not all issues, conditions, and problems dealt with in psychotherapy are reimbursed by insurance companies.
CANCELLATIONS & MISSED APPOINTMENTS
Insurance carriers will not pay for late cancellations or missed appointments. Once an appointment is scheduled, that time is reserved specifically for you. Cancellations must be made at least 24 hours in advance. Although 24 hours is the minimum, if you need to cancel or reschedule please give as much notice as possible. You may notify our office of cancellation by phone or email to your provider. Late cancellations (fewer than 24 hours before the appointment) will incur a fee (initial evaluation $175, follow-up appointment $75, therapy appointment $125). If there are two or more missed appointments without 24hr notice within a 6 month period, please understand this may lead to termination from the practice.
Upon scheduling your first appointment you will need to provide credit card information which will be kept on file to be used as a form of payment for fees incurred for co-pays, co-insurance, deductibles, late cancellations, missed appointments, returned checks, or past due account balances. A receipt will be e-mailed to you at the address you specify below at your request or by email.
Please note that missed appointments are quite disruptive to our practice and this time cannot be recovered to provide care for other individuals. As such we require credit card info prior to the first appointment. In scheduling your initial evaluation and providing credit card information, you are authorizing the no-show fee charge as indicated above. Thank you for your understanding with this matter.
I have read the Agreement and Policy above, and I have been offered a copy for my records. I understand the policy and by my signature below I agree to be bound by its terms in association with outpatient services provided to me by Pacific Mind Health. Any and all negotiated exceptions or special arrangements are listed below and require approval and are not valid unless signed by a representative of Pacific Mind Health.