It is your responsibility to contact your insurance company to confirm that Insight Mental Wellness is on your insurance panel, acquire pre-authorization for treatment, and confirm your personal policy benefits for “Outpatient Mental Health with Insight Mental Wellness” services before your first appointment. Be sure to state that this is for “outpatient mental health with Insight Mental Wellness” benefits, obtain information on your eligibility status, policy deductible, co-payments, co-insurance, and if needed provide information for the clinic or provider. It is the patient’s responsibility to understand their insurance benefits prior to being seen at Insight Mental Wellness (IMW). I understand and agree that if my insurance company denies services provided by IMW, it is my responsibility. Balances on my account are to be paid in full within 30 days of service. Self-pay patients and copays are required to be paid in full on the date of service with NO exceptions

It is our number one priority at IMW to provide the best quality of care to all of our patients. We understand that situations come up in life that are out of your control, however we do have lists of patients that would like to be seen as soon as possible. The clinic does provide courtesy reminder text messages. However, it is primarily your responsibility to call and make changes to your appointment no later than 48 hours in advance in order to prevent charges. For an initial evaluation appointment, we will charge a fee of $220 (insured) and $280 (self-pay), for an appointment rescheduled or canceled later than 48 hours/no-show, to your credit card on file. For follow up appointments, we will charge a fee of $125 (insured) and $150 (self-pay) for an appointment rescheduled or canceled later than 48 hours/no-show to your credit card on file. There is a fee of $125 for any psychotherapy/psychological evaluation appointment rescheduled or canceled later than 48 hours/no-show. All fees must be paid prior to your next date of service. IMW reserves the right, after a second and third no show/same day cancellation, to terminate the patient services.

It is the patient’s responsibility to schedule and maintain your appointments with the clinic. For all medication refill requests after a canceled/rescheduled/no-show appointment will be assessed a $25 fee per prescription. Refill will be for 2 weeks with a follow up scheduled immediately. a patient can choose to come to the clinic for a walk-in session based on space availability in order to avoid this fee. Insight Mental Wellness reserves the right to terminate services after 2 incidents of rescheduling/no-shows/or same day cancellation of appointment. If the applicable fees are not paid by the follow up appointment, we will not be able to schedule another appointment and the patient may be discharged from the practice.

Allow a minimum of 2 clinic visits prior to completion of any documents. When requesting a letter or healthcare related documents to be completed by a provider, understand that the completion of these letters or documents will be at the provider’s discretion. There is a standardized charge for this service. Most insurance companies will not reimburse for these charges, and it is the responsibility of the patient to pay for the fees. Please allow at least five (5) business days for completion of these requests.

Insight Mental Wellness clinic and staff DOES NOT provide any form of legal presentation to include but not limited to custody, visitation, any forensic matters or legal administrative proceedings. The clinic will respond to any legal subpoena on your medical record. However, you will be responsible for any fees related to the clinic and staff time related to legal matters. Starting at $350/hr + any other expenses related to the event. Charges for court related services are not covered by insurance.

Any information about past surgical and medical histories (you can also complete these information on your forms in the patient portal prior to visit) Contact information for your doctor, therapist, pharmacy, etc. We highly recommend you bring all current prescriptions and over the counter medication bottles for review during the initial visit and only prescription bottles by the clinic for follow up appointments. Your personal form of ID such as a driver’s license.

Insight Mental Wellness enlist the services of prequalified clinic staff and assistants/technicians to facilitate your treatment plan/care. The clinic staff may include Licensed Vocational Nurse, Medical Assistants, and Medical Receptionist. We strive to provide learning opportunities to specialty graduate students in the mental health field. The clinic assistants/technicians may include Associates and Interns from the following field of learning: Student Psychiatric Nurse Practitioners, Licensed Masters Social Workers, Licensed Masters Family Therapist, and Licensed Practicing Counselor. During the course of your treatment at the clinic, you may have supervised encounters with any of our staff/assistants. Any concerns or reports will be reviewed, and responses communicated with you directly.

Right to file a complaint if you feel we have violated your rights, if you have a concern about your treatment at the clinic, or about your billing statement, by contacting us at 2102457862 or staff@imwellness.com. We will take your concerns seriously, openly, and respond respectfully. You may request to speak with the Office Manager. You have specific rights under the Privacy Rule. We will not retaliate against you for exercising your right to file a complaint.

Right to Request Restrictions –You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, we are not required to agree to a restriction you request. We will provide you with a reason for disagreement within 60 days. Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI (Protected Health Information) by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing us. Upon your request, we will send your bills to another address.)

Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI and/or notes in our mental health and billing records used to make decisions about you for as long as the PHI (Protected Health Information) is maintained in the record. We may deny your access to PHI (Protected Health Information) under certain circumstances, but in some cases, you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process. We will provide a copy or summary of your health record, within 30 days of your request. Contact the clinic for any applicable charges or fees.

Right to Amend – You have the right to request an amendment of PHI (Protected Health Information) for as long as the PHI (Protected Health Information) is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process. We will review the reason for denial of request in writing within 60 days.

Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI (Protected Health Information) for which you have neither provided consent nor authorization. On your request, we will discuss with you the details of the accounting process.

Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket – You have the right to restrict certain disclosures of PHI (Protected Health Information) to a health plan when you pay out-of- pocket in full for our services.

Right to Be Notified if There is a Breach of Your Unsecured PHI (Protected Health Information) – You have a right to be notified if: (a) there is a breach (a use or disclosure of your PHI (Protected Health Information) in violation of the HIPAA Privacy Rule) involving your PHI (Protected Health Information); (b) that PHI (Protected Health Information) has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI (Protected Health Information) has been compromised. Effective Date, Restrictions, and Changes to Privacy Policy We are required by law to maintain the privacy of PHI (Protected Health Information) and to provide you with a notice of our legal duties and privacy practices with respect to PHI (Protected Health Information). We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect. If we revise our policies and procedures, we will provide you with a revised notice by email, unless you have requested to not be contacted via email, in which case we will provide you with a revised notice via mail to the address you have provided. This notice is effective as of January 3, 2022. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI (Protected Health Information) that we maintain. We will provide you with a revised notice by email, unless you have requested to not be contacted via e- mail, in which case we will provide you with a revised notice via mail to the address you have provided.

The clinic reserves the right to terminate care if a case of patient noncompliance with treatment plan/medication management/follow up recommendations becomes the barriers to a successful treatment. We encourage you to discuss any concerns you have about our work together. Other factors that may result in termination of treatment by the clinic include, but are not limited to, violence or threats toward clinic/staff, irreconcilable differences, or refusal to pay for services in duetime. Insight Mental Wellness reserves the right to terminate services after 2 incidents of rescheduling/no-shows/or same day cancellation of appointment. If the applicable fees are not paid by the follow up appointment, we will not be able to schedule another appointment and the patient may be discharged from the practice. Referrals - At IMW we are glad to receive from others and refer to other providers for continuation of care or collaborative care. (Example, physicians, other therapists, employee assistance programs, etc.) We may also recommend that you see another provider, such as a medical specialist or specialized therapist, if it is felt that a more comprehensive consultation is warranted. Be sure to arrive 15-30 minutes prior to your scheduled appointment to complete any necessary paperwork. It is our goal to service you in due time. Completing all paperwork needed for your visit on the patient portal or before coming in for your appointment can facilitate a timely visit with less delay. Situations may arise during the course of a visit with a patient which can result in delays, I hope that those are rare instances.

Insight Mental Wellness has a clinic policy, which requires you to maintain your credit card/HSA/ or Flex spending card information securely on file with the clinic. In providing us with your card information, you are giving Insight Mental Wellness permission to automatically charge your credit card on file for your [or any other patient(s) you have listed on this form] co-pay, self-pay, and any other forms of fee for service as agreed upon at the time of service. By signing this you authorized this agreement will remain in effect until the expiration of the credit card account and that you may revoke this form at any time by submitting a written request.

Co-pays: are due at the time of the office visit. Self-Pay Services: Payments are due at the time of the office visit. Other Services: To include paperwork, personal medical record, and any other agreed upon services, payments are due at the time of the office visits.

Outstanding Balance: If your insurance provider has paid their portion of your bill [or any other patient(s) you have listed on this form] and there is an outstanding balance owed, Insight Mental Wellness will notify via phone and /or email. If by the final billing notice, we do not receive a response from you or your payment in full, at that time, any balance will be charged to your credit card. A copy of the charge will be sent by email or mailed to you. This in no way should compromise your ability to dispute a charge or question your insurance company's determination of payment.