In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources I have available to pay for my treatment. If I have a health insurance policy, it will usually provide some coverage for mental health treatment. With my permission, my therapist will assist me to the extent possible in filing claims if she is an in-network provider for my insurance. I understand that I am responsible for knowing my coverage (including co-insurance and co-pays) and for letting Accepted Therapy Service know if/when my coverage changes. If my therapist is not a participating provider for my insurance plan, I understand that she will supply me with a receipt of payment or superbill, upon request, for services which I can submit to my insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers. If I prefer to use a participating provider, my therapist will refer me to another mental health professional.

I am aware that most insurance companies require my therapist to provide them with a clinical diagnosis/diagnoses. (Diagnoses are technical terms that describe the nature of my problems and whether they are short-term or long-term problems. All diagnoses come from a book entitled the Diagnostic and Statistical Manuel 5th Edition or DSM-5. There is a copy in my therapist’s office that I can look at if I would like to learn more about my diagnosis, if applicable.). Sometimes my therapist may have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I recognize that my therapist does not have control over what the insurance company does with it once it is in their hands. In some cases, they may share the information with a national medical information databank. If I want a copy of any report my therapist submits, I can request it at any time. By signing this agreement, you agree that I can provide requested information to your carrier if you plan to pay with insurance.

In addition, if I plan to use my insurance, authorization from the insurance company may be required before they will cover therapy fees. If I do obtain authorization and it is required, I may be responsible for full payment of any fees accrued. Many policies leave a percentage of the fee (which is called co-insurance) or a flat dollar amount (referred to as a co-payment) to be covered by me (the client). Either amount is to be paid at the time of the visit via any of the accepted payment methods. In addition, some insurance companies also have a deductible, which is an out-of-pocket amount, that must be paid by me (the client) before the insurance company is willing to begin paying any amount for services. This will typically mean that I will be responsible to pay for initial sessions with my therapist until my deductible has been met. The deductible amount may also need to be met at the start of each calendar year. Once we have all of the information about your insurance coverage, we will discuss what we can reasonably expect to accomplish with the benefits that are available and what will happen if coverage ends before I feel ready to end my sessions. I understand that I always have the right to pay for my therapy services out-of-pocket if I wish to avoid any of the problems described above.