Interactions Counseling and Intervention Center, Inc.

Health Insurance Information and Client Payment Agreement

This is an agreement between (your name),______and Interactions Counseling regarding billing and payment of your therapy sessions. Interactions will bill your insurance for your sessions. However, because health insurance products change so frequently, it is often difficult to know exactly what your coverage is. In order to assist us in correctly billing you and your insurance, please contact your insurance company before your first session and have them answer the following questions. It is your responsibility to know your coverage and communicate that information to your therapist. You are responsible for knowing and keeping track of any deductible associated with your plan and paying your deductible portion at each session.This way, you will not get any surprises (at a financial cost to you) if your coverage is different than you thought.

Interactions Counseling will keep track of the number of sessions used through Interactions so you don't exceed the designated number or amount of money allocated to you. It is in your best interest for you to also keep track of the number of sessions used as some plans count prior therapies as part of your yearly session benefit.

Please note that you are responsible for full payment of sessions when insurance payments are delinquent past 5 months or denied for any reason.

Contact the Behavioral Health number on your card if there is one, or the Customer Service number if that is all there is and ask the following questions: (Please bring this form, your insurance card and co-pay or session deductible amount to your first appointment.)

Insurance Company ______Plan ______

Name and Phone # of person you spoke with ______

  1. Is Interactions Counseling and Intervention Center, NPI # 1760583736 an approved provider under my plan? Yes No
  1. Do I need an authorization number for Behavioral/Mental Health benefits? Yes No

Auth # ______

How many visits do I get on the first authorization, (this is different from the number of visits you get for the full calendar year). ______

  1. Do I have a deductible for Outpatient Mental Health and if so: how much is it? ______

How much is left on my deductible? ______

  1. Do I have a Co-insurance or a Co-pay? If it is a Co-insurance what percent is my portion? ______

If a Co-Pay, how much per visit?______

If you have a Co-Insurance plan, how does this work during your deductible period and then after your deductible is met? (Use other side if necessary).

Thank you for assisting us in understanding your insurance. This information will help all of us avoid any unexpected out of pocket fees that could occur if you do not understand how your policy works.

I have read, understand and agree to the above policy and procedures regarding use of my health insurance.

______

Signature of Client or GuardianDate