Financial Policy for Kimberly Brodie and Associates, Inc.
Trading as AwakeningsCounselingCenter
Welcome and congratulations on your decision to seek self improvement and a higher quality of life through skilled professional counseling. We know your decision could be one of the most important investments you will ever make in yourself. Money and financial arrangements are most often on a client’s mind when they first seek counseling, therefore we want to help you understand and comply with our financial policies.
PAYMENT: Payment for services is due on the day and at each time services are provided. If you are requesting that your insurance benefits be applied, you must contact the office and provide all necessary information prior to the day of your first appointment. Most insurance companies require preauthorization and it is the client’s responsibility to obtain the required authorization. Insurance co-payments or any deductible amount is due at the time of service. If you need assistance with your insurance information please contact the office prior to the day of your visit.
NSF/RETURNED CHECKS: Checks returned for insufficient funds will result in a charge of $40.00 per check.
CANCELLATION POLICY: If you find that you will be unable to keep your appointment or attend a group, you must call to notify the office at least 24 hours in advance of your appointment. Failure to give 24 hour notice will result in you being charged for the service. The charge is $55.00 and must be paid prior to the next scheduled visit. Missed/Failed appointments are not insurance reimbursable. As a courtesy, our office staff will provide you with a reminder call for appointments, but not receiving a call or missing the reminder call is not an acceptable excuse for failing to show for an appointment or missing an appointment. You will still be held responsible.
INSURANCE: Our payment policy includes the acceptance of most major insurance companies for Traditional Face to Face Counseling. At this time, we do not bill insurance companies for Distance Counseling Services. We are members of many local and national health care networks. Even though you may be insured, it is important to remember that the policy that you have with your insurance company is between you and the insurance company. As the provider, we are not involved in this agreement. Consequently, your agreement to pay us is separate from, but may include, your insurance payment. Our office will be happy to verify your benefits, and assist you as much as possible with your insurance. If you have more than one insurance, you are required by law to notify us. Securing insurance payments may require your active participation.
BILLING: After each visit we will send in a claim to your insurance company for payment of the services that have been provided. In order to keep overhead expenses down,we will not be sending out monthly client billing statements. Current fees for the following services are: Evaluation / $155.00; Individual Therapy / $125.00; Family Therapy / $125.00; Group
Therapy / $75.00
COLLECTIONS: In the event that a client’s account becomes 30 days delinquent, it will be sent to a Collection Agency. The client will be responsible for the cost of all attorney and collections fees. Non-payment of any fees due by any client will result in termination of services.
AGREEMENT: I have read the above financial policies and agree to abide by them. I understand that fees for each service are due at the time the service is rendered and each time thereafter. I also understand that if any account becomes delinquent I will be responsible for all attorney and collections fees. I understand that I am responsible for all charges incurred during the course of my treatment. Lastly, if I need assistance with my insurance or have any financial questions, the above office will be happy to assist me. A signed copy of this agreement will be placed in my medical record.
Client SignatureDateParent or Legal GuardianDate
Revised 2/12