PAYMENT & CANCELLATION


Cancellation Policy

No shows, cancellations, or rescheduling an appointment with less than 24 business hours notice,

will be responsible to pay a fee of $50.



For example, 

We are open from Monday thru Friday of each business week.

if an appointment is on Tuesday at 10am, you will communicate any changes no later than the day before,

Monday by 10am.

if you, or your child's appointment is on Monday at 4pm, you will communicate your cancellation no later than the Friday before that weekend at 4pm. (Business hours apply).

If you do not reschedule or notify us of the changes to an appointment time or date, as agreed to in the above terms, your credit card will be charged for the full amount of an intake session, at our current rate as listed in the following section.



Cash Payment Policy

If you do not supply insurance information, Payment for appointments will be charged to the

credit card you upload before any appointment can be confirmed.

You agree to pay the entire cost upfront for any services scheduled, before they are provided.

You agree to pay professional fees as follows: 



Initial Intakes: (Mandatory for care)

$400.00 PER  60 MINUTE INTAKE SESSION



Medication Management:

$200.00 PER FOLLOW UP 



Therapy:

$400.00 PER 60 MINUTE SESSION



You agree to pay for any time spent in your, or your child's care outside of session time on a prorated basis (unless otherwise detailed below).

Unfortunately, insurance companies typically do not reimburse for this. Some examples include, but are not limited to:



* No shows/rescheduling with less than 24 business hours notice

* Phone calls, messages in the patient portal, voicemails, letters, video sessions and texts between me and: you, your child, or other physicians, therapists, teachers, family members, insurance companies, etc.

* Prescription refills outside of session time

* Time spent obtaining prior authorizations

* Coordination of care for emergencies, hospitalization, intensive outpatient, residential treatment, rehabilitation, etc.

* All forms (insurance, worker's compensation, school, employer; doctor's notes, letters, or reports) and chart reviews not filled out in session

* Testimony in court, at depositions, administrative hearings, board reviews, and all time required for preparation and travel, whether requested by you or ordered by a court, board, government agency or other legal authority

* There is a 10% finance charge each month and a $30 late fee for balances more than 30 days past due, 

and they may be submitted to collections after 30 days, along with any associated collections fees

* There is a $50 fee for returned checks (which will also result in your credit card automatically being run for the balance due) and for credit card chargebacks that are unsubstantiated.



You are financially responsible for all charges, whether or not:
* Insurance pays for any services

* We decide to proceed with treatment

* Treatment is successful, for which there cannot be any guarantee



**for in-network providers**

For in-network services, I will submit claims on your behalf as a courtesy, but there is no guarantee that your insurance will pay. 



You are responsible for full payment, whether your insurance company ends up paying partially, or not at all, for services rendered.



You affirm you are an authorized user of the credit card whose number and expiration date supplied, and you do authorize its use for all fees incurred.



By typing your signature below, you confirm you have read the above and agree to these terms and conditions.



I have read and understand the information provided above regarding Tele-psychiatry.

I have discussed it with my provider and all of my questions have been answered to my satisfaction.

My signature below affirms that I hereby give my informed consent for the use of Tele-psychiatry in my health care and authorize my provider to use Tele-psychiatry in the course of my diagnosis and treatment.