Financial Policy & Agreement for Services

I understand that I am ultimately responsible for the cost of all professional services provided. Payment is due at the time of service unless a prior written arrangement has been made.

• Accepted Methods: Credit/Debit, HSA/FSA, ACH. *If ACH [checks] are returned, the therapist has a right to refuse ACH as a future payment method.
• Auto-Pay: By providing a card on file, I authorize [Fayona Curenton, LISW-CP, LISW-S and Mental Wellness & Clinical Counseling Services, LLC] to charge my account for services rendered on the day of my appointment.

As a courtesy, this practice can provide a monthly superbill at the request of the client to submit to their health insurance carrier for reimbursement. However:

• Authorization: I authorize a monthly superbill to be sent electronically to me.
• Accuracy: I am responsible for ensuring the superbill is accurate [i.e., date of service, length of appointment, etc.]. If a claim is denied for reimbursement due to inaccurate information, it is my responsibility to notify the therapist within 30 days of denial, or the full balance becomes my responsibility.
• Scope of Coverage: I understand that "mental health benefits" often differ from general medical benefits. It is my responsibility to verify my "out-of-pocket" maximums.

To maintain a consistent therapeutic schedule and respect the therapist's time, the following policy applies:

• Notice Requirement: A minimum of 24 hours' notice is required to cancel or reschedule an appointment.
• Late Fee: Failure to provide sufficient notice will result in a "Late Cancellation Fee" of $25.
• Insurance Restriction: I acknowledge that insurance companies do not reimburse for missed appointments; therefore, this fee must be paid out-of-pocket.

I understand that additional fees may apply for services performed outside of my scheduled session time, including:

• Completion of complex forms or disability paperwork.
• Preparation of treatment summaries or legal affidavits.
• Lengthy phone consultations (exceeding 15 minutes).
• Professional court appearances or depositions.

I have the right to receive a "Good Faith Estimate" explaining how much my medical care will cost. Under the law, health care providers must give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

• I can ask for a Good Faith Estimate before I schedule a service.
• If I receive a bill that is at least $400 more than my Good Faith Estimate, I can dispute the bill.

In the event that an account remains unpaid for over 60 days without a payment plan in place, the practice reserves the right to utilize a collection agency or small claims court. I understand that in such cases, only the minimum necessary information (name, contact info, and balance due) will be disclosed.

[Adapted from Blueprint.com forms. Information can be sent electronically via Blueprint.com for clients who schedule an appointment]