Athena Consulting & Psychological Services, LLC

Office Policies and Consent for Treatment

Responsibility for Payment

Payment for services is expected at the time of service.

If you have insurance or a managed care program that limits the amount you are required to pay, we will honor those arrangements, provided we participate in that program.

Your co-payment is expected at the time of each session.

Insurance is billed as a courtesy. If the insurance company should refuse payment, or provide any other obstacle to reimbursement, the patient may be held responsible for payment and may seek reimbursement directly from the insurance provider. Secondary or supplemental insurance must be presented at the initial appointment.

Additional fees may be incurred for non-insurance based paperwork to include but not limited to: FMLA, Disability paperwork, School Forms, etc….fees can range between $20 and $40 based on extent of paperwork.

Missed Appointments

______We require 24 hours notice for all cancellations.

______Cancellations made the day of your appointment will result in a charge of $50 and assessment or testing appointment cancellations will result in a charge of $150. Missed appointments cannot be billed to your insurance company. (Emergency situations are an exemption, and your provider makes the same considerations when canceling).

Outstanding Balances

Statements are mailed every 30 days for any outstanding balance due. Once your insurance company has provided payment or official response, you are completely responsible for the difference. Balances more than 30 days past due are subject to late fees and those more than 90 days past due are subject to collection. Payment plans must be arranged in advance. Additionally, Athena reserves the right to contact and use a collection agency to collect any/all outstanding monies owed. Further, costs for those services are included in the fees collected.

Reduced Fees

Fees are occasionally reduced when participating in contracted service programs such as; EAP’s, specific provider referral programs, and sliding scale cash arrangements due to financial hardship. Such arrangements must be made in advance, and insurance companies cannot be billed when using such fee arrangements.

Confidentiality

All legal and reasonable efforts are made to protect your confidentiality. Please discuss any exceptions of this with your individual provider. However, consultation regarding your treatment may occur within Athena to coordinate and assure the quality of the care you receive, in accordance with the ethical standards of the practice of psychology and psychiatry.

______If this is for a minor child, I am the legal parent/custodian/guardian and I have the right to consent to treatment for this minor. My signature below indicates my consent. Any misrepresentation of your ability to consent to the child’s treatment is a violation of the law and subject to civil and criminal penalties.

I have read the above statements concerning responsibility for payment, missed appointments and outstanding balances and agree to these terms of services. I am aware of all HIPAA regulations concerning treatment and understand that the information is available to me upon request. Additionally, I give permission for Athena Consulting & Psychological Services, LLC to bill my insurance for rendered services and understand that by signing below I may be held responsible for all outstanding balances. I agree to all of the risks and benefits associated with psychological treatment.

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PRINT Name Social Security Number of Person Signing

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Signature Date