BUSINESS POLICY AND CLIENT AGREEMENT
Welcome to our practice! This agreement contains information about our professional services and business policies. So that misunderstandings regarding our Business Policy and Patient Agreement may be avoided, the following is prepared for you. Please read this carefully. Our CEO or the professional whom you are seeing will be happy to discuss any questions that you may have.
FEES FOR SERVICES:
Our initial visit is $195. Subsequent visits are $160. Most insurances are accepted with the exception of Medicaid and NC Healthchoice or United Healthcare. We accept Cash, Check, Visa, Mastercard, American Express & Discover as well as HSA. We do accept self pay.
LATE CANCELLATIONS AND MISSED APPOINTMENT POLICY
Scheduled appointments are reserved strictly for you and for no one else. Because of this, we require a 24 Hour Notice to cancel or change your appointment. Please let us know if you are unable to keep an appointment that you have scheduled, otherwise, you may be charged a late cancellation or a no show fee for the time that was reserved by you for you ($80.00 for individual therapy sessions and $30.00 for group sessions).
SEPARATION/DIVORCE POLICY
For parents who are separated, pending separation, divorced, or engaged in litigation we do require a Special Contract from the parents.
In separated or divorced families, the person who initiates services with us is held financially responsible. We do not bill another person or an estranged spouse unless that individual informs us in writing of his or her willingness to pay for services rendered. Should another party be willing to assume financial responsibility for our services, they may contact our office and ask for our CEO, Chimene Mathis.
PAYMENT POLICY
Payment for all services is due at each session. Services may be interrupted until payment is made. Finance charges are added if you do not make a payment within 30 days. Late charges are computed at one & 1⁄2% monthly (18% annually) for any balance over 30 days old. Final payment is expected on behalf of the client before reports, including psychological evaluations, are released. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure payment. This may involve hiring a collection agency or going through small claims court, which will require us to disclose your name, address, phone number, and the amount due. If legal action is necessary, the cost will be included in the claim.
HEALTH INSURANCE POLICY
Services provided by our office are covered under Mental Health insurance provisions. Since plans are so varied, please check your policy to make sure you understand benefits and limitations. If you belong to a Managed Care Plan or PPO, you must have proper authorization for your visits prior to your first visit with us. Please be aware that not all services are covered by insurance policies (e.g., school visits).
In the event that insurance coverage changes, it is the responsibility of the patient to notify Sylva Clinical Associates and to accept financial responsibility for services denied due to the change.
We are providers for Medicare, Crescent, Tricare/Champus/ChampVA, Blue Cross Blue Shield, MedCost, and most other private insurances.
Unfortunately we are NOT providers for Medicaid and NC Health Choice or United Healthcare.
CONFIDENTIALITY POLICY
The associates of Sylva Clinical are a collaborative practice of professionals. To provide you with the best care possible, we consult with one another when clinically advisable. If your therapist is out of town or for some reason unavailable, it is important that the associates in the practice have access to relevant information in order to provide the best possible care for your family.
The confidentiality of the work that we conduct together with you as a client is upheld at all times. However, there are certain exceptions to this rule:
PATIENT / THERAPIST COMMUNICATIONS
Phone:
If you need to contact us between sessions, the best way to do so is by phone at 828-586-5555 and either ask to speak directly with us or leave a brief message with our office administrator, Brittany Buttery. We make efforts to check our mailboxes on a daily basis, Monday through Thursday.
E-mail:
We prefer to use emails primarily for inquires about office procedures, billing practices or administrative matters. We have a general office mailbox but please do not use this to email content related to your therapy sessions, as it is not completely secure or confidential. If you do choose to communicate by email, be aware that all emails are retained in the logs of internet service providers. Any emails that you send to us should contain non-urgent matter, as the timeliness of email review cannot be guaranteed. If you are experiencing an emergency, you should go to your local hospital emergency room.
Friending and Text Messages:
We do not accept friend or contact requests from current or former clients on any social networking site (Facebook). As a general rule, we do not accept text messages, Twitter, or any other form of social media. We believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when you speak with the office staff or your therapist. If we should have to contact you after hours or on weekends using our personal cell phones, we ask that you respect our privacy and direct any future calls to our business phone numbers.
Welcome to our practice! This agreement contains information about our professional services and business policies. So that misunderstandings regarding our Business Policy and Patient Agreement may be avoided, the following is prepared for you. Please read this carefully. Our CEO or the professional whom you are seeing will be happy to discuss any questions that you may have.
FEES FOR SERVICES:
Our initial visit is $195. Subsequent visits are $160. Most insurances are accepted with the exception of Medicaid and NC Healthchoice or United Healthcare. We accept Cash, Check, Visa, Mastercard, American Express & Discover as well as HSA. We do accept self pay.
LATE CANCELLATIONS AND MISSED APPOINTMENT POLICY
Scheduled appointments are reserved strictly for you and for no one else. Because of this, we require a 24 Hour Notice to cancel or change your appointment. Please let us know if you are unable to keep an appointment that you have scheduled, otherwise, you may be charged a late cancellation or a no show fee for the time that was reserved by you for you ($80.00 for individual therapy sessions and $30.00 for group sessions).
SEPARATION/DIVORCE POLICY
For parents who are separated, pending separation, divorced, or engaged in litigation we do require a Special Contract from the parents.
In separated or divorced families, the person who initiates services with us is held financially responsible. We do not bill another person or an estranged spouse unless that individual informs us in writing of his or her willingness to pay for services rendered. Should another party be willing to assume financial responsibility for our services, they may contact our office and ask for our CEO, Chimene Mathis.
PAYMENT POLICY
Payment for all services is due at each session. Services may be interrupted until payment is made. Finance charges are added if you do not make a payment within 30 days. Late charges are computed at one & 1⁄2% monthly (18% annually) for any balance over 30 days old. Final payment is expected on behalf of the client before reports, including psychological evaluations, are released. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure payment. This may involve hiring a collection agency or going through small claims court, which will require us to disclose your name, address, phone number, and the amount due. If legal action is necessary, the cost will be included in the claim.
HEALTH INSURANCE POLICY
- Insurance claims - As a courtesy, we will file insurance for you under most circumstances as long as you provide us with current information on your insurance plan. Each plan has different benefits for you as well as different financial obligations. Not all insurance policies cover all services. You are ultimately responsible for understanding the details of any particular coverage you may have as well as the payment of all charges you incur.
- Insurance Card- please provide a copy of your insurance card prior to each visit.
- Unpaid Insurance Claims - If your insurance company has not responded to us within 60 days of a filed insurance claim, the charges will be sent to you directly and you will be responsible for their payment as well as for payment of any other charges incurred consistent with this financial policy.
Services provided by our office are covered under Mental Health insurance provisions. Since plans are so varied, please check your policy to make sure you understand benefits and limitations. If you belong to a Managed Care Plan or PPO, you must have proper authorization for your visits prior to your first visit with us. Please be aware that not all services are covered by insurance policies (e.g., school visits).
In the event that insurance coverage changes, it is the responsibility of the patient to notify Sylva Clinical Associates and to accept financial responsibility for services denied due to the change.
We are providers for Medicare, Crescent, Tricare/Champus/ChampVA, Blue Cross Blue Shield, MedCost, and most other private insurances.
Unfortunately we are NOT providers for Medicaid and NC Health Choice or United Healthcare.
CONFIDENTIALITY POLICY
The associates of Sylva Clinical are a collaborative practice of professionals. To provide you with the best care possible, we consult with one another when clinically advisable. If your therapist is out of town or for some reason unavailable, it is important that the associates in the practice have access to relevant information in order to provide the best possible care for your family.
The confidentiality of the work that we conduct together with you as a client is upheld at all times. However, there are certain exceptions to this rule:
- If the therapist suspects child abuse or if there is reasonable cause to believe that a disabled adult is in need of protective services, then appropriate authorities are contacted.
- If a therapist believes that you are a clear and imminent danger to yourself or another person, the therapist may notify appropriate others to prevent the occurrence.
- If there is need for healthcare oversight, the North Carolina Psychology Board has the power, when necessary, to subpoena relevant records from our practice if we are the focus of an inquiry.
- If there are legal proceedings, patient/therapist communications are privileged except for the following:
- If your mental status is an issue before the court.
- If the judge authorizes a court order because he or she feels that communication is necessary to the proper administration of justice.
- If a government agency is requesting information for health oversight activities, we may be required to provide it for them.
- If a complaint or lawsuit is lodged against us, we may disclose relevant information regarding that patient in order to defend our practice.
- If a patient files a worker’s compensation claim, we are required by law to provide mental health information to your employer and the North Carolina Industrial Commission.
PATIENT / THERAPIST COMMUNICATIONS
Phone:
If you need to contact us between sessions, the best way to do so is by phone at 828-586-5555 and either ask to speak directly with us or leave a brief message with our office administrator, Brittany Buttery. We make efforts to check our mailboxes on a daily basis, Monday through Thursday.
E-mail:
We prefer to use emails primarily for inquires about office procedures, billing practices or administrative matters. We have a general office mailbox but please do not use this to email content related to your therapy sessions, as it is not completely secure or confidential. If you do choose to communicate by email, be aware that all emails are retained in the logs of internet service providers. Any emails that you send to us should contain non-urgent matter, as the timeliness of email review cannot be guaranteed. If you are experiencing an emergency, you should go to your local hospital emergency room.
Friending and Text Messages:
We do not accept friend or contact requests from current or former clients on any social networking site (Facebook). As a general rule, we do not accept text messages, Twitter, or any other form of social media. We believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when you speak with the office staff or your therapist. If we should have to contact you after hours or on weekends using our personal cell phones, we ask that you respect our privacy and direct any future calls to our business phone numbers.