I am committed to providing the most effective and efficient social work treatment and services possible. To do so, I need your understanding of my fee policy and the reasoning behind it, as well as your cooperation.
Payment Schedule
Payment is due at the time services are rendered, unless other arrangements have been approved in advance. By having you pay at each session, I eliminate the need to bill you. This helps keep my costs as low as possible, prevents the accumulation of large debts on your part, and avoids possible risks to your privacy that occur when invoices for service are mailed to you. I encourage you to contact me immediately for assistance if temporary financial problems affect the timely payment of your account.
Services Not Covered
Regardless of the nature of your third-party payer, some of the services you receive may not be covered under your mental health benefit. Responsibility for payment for those services rests with you. However, non-reimbursable services will be thoroughly discussed with you before they are provided, and you will have full opportunity to refuse such services and to consider alternatives.
Payment Methods
I accept cash, money orders, and personal checks*. I accept credit card payments through website with my secure online PayPal account. You do not need a PayPal account to make a payment with your credit card. You can make your credit card PayPal payment at www.jennifermoorecounseling.com , click on “PayPal” link from the home page.
*Returned checks will be subject to a $35.00 charge, which will be added to your bill.
Unpaid balances older than 60 days and in excess of $200.00 will be the basis for terminating service. In this unfortunate event, I will make every effort to help you locate alternative affordable care; however, I will be unable to continue to work with you in the face of financial default.
The law allows the referral of unpaid bills to a collection agency or the utilization of small-claims court procedures. Note that this is not the preferred course of action, but may become necessary if the problem of a delinquent account cannot be resolved otherwise.
Charges for Late and Cancelled Appointments
I require 24 hours’ advance notification if you are not able to keep a scheduled appointment. This notice permits me to offer that time to someone else. If you have given 24 hours’ notice, you will not be charged for the appointment. However, if you break your appointment and do not call this office within 24 hours, you may be charged for the session.
I understand that there may be occasional emergencies when you will not be able to keep your appointment and also will not be able to notify me within 24 hours. I will take these circumstances into account.
Charges for broken appointments and appointments cancelled without 24-hours’ notice cannot be billed to your third-party payer. You will be personally responsible for the contracted rate of your health plan or individual self payment plan not cancelled within 24 hours.
If you are late for your appointment without 24 hours’ notice, you will be seen for the balance of your time but charged for a full session. If you provide 24 hours’ notice of an expected late arrival, your fee will be prorated.
By signing below I am indicating that I have read the above statements on fees and payment policies. I have discussed these conditions with Jennifer Moore, LCSW and have had the opportunity to ask any questions I have had. My questions have been answered to my satisfaction. I understand and agree to meet my financial responsibilities in receiving treatment and services in this practice setting.
I, undersigned that I (or my spouse or dependent) have insurance/EAP coverage with _____________________________________(my $ responsibility _______)
And assign directly to Jennifer Moore, LCSW all benefits if any and otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance/EAP. I hereby authorize Jennifer Moore, LCSW to release all necessary personal health information to secure the payments of benefits. I authorize the use of this signature on all insurance/EAP submissions
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CLIENT’S SIGNATURE (GAURDIAN’S SIGNATURE IF CLIENT IS A MINOR) DATE
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Jennifer Moore, LCSW DATE