Thank you for choosing Aspiring to Change Counseling Services. Please review this Fee Agreement and Financial Policy (the “Agreement and Policy”), which describes our schedule of fees for services, charges not covered by insurance, and additional fees. Please be sure you understand the policies regarding cancelations and missed appointments, methods of payment, insurance reimbursement, and past-due accounts.
If you have any questions about anything, please ask your provider prior to signing this Agreement and Policy. Our service rates and corresponding health insurance billing codes (numbers starting with ‘90’ refer to mental health services) this is not a comprehensive list and reflect the most common services provided by our staff. Additional codes may be used by your provider as deemed appropriate.
- 90837 Individual Therapy (45-60 min.) $195.00
- 90832 Brief Individual Therapy (27-37 min.) $135.00
- 90847 Family Therapy w/ patient present (45-60 min.) $215.00
- 90846 Family Therapy w/o patient present (45-60 min.) $210.00
- 90849 Family Therapy w/o patient present (60-80 min.) $260.00
- 90853 Group Therapy (90 min.) $35.00 per client
- 90791 Initial Intake Assessment (60 mins) 225.00
- 90834 Brief Individual Therapy (38-44 minutes)- 160.00
Late cancelations/Missed Appointment – fewer than 24 hrs. prior to appointment $35.00
- Past-due accounts – over 30 days $25.00 per month
- Checks returned due to insufficient funds will incur a fee of $45.00
- If a credit card is declined due to insufficient funds, a $25 processing fee will be assessed to the invoice and must be paid prior to the next session
You will be expected to pay for either each session in full or your insurance co-payment at the time of services provided under the Outpatient Services Agreement, which will be given to you along with this Agreement and Policy and our Notice of Privacy Practices. Accepted methods of payment are cash, check, or credit cards. To comply with the PCI standards, set by the State of Michigan, Aspiring to Change Counseling Services will charge a rate of 3.15% + 0.30 to each payment submitted electronically to a credit/debit card. This will cover the exact cost of the current EHR system that Aspiring to Change Counseling Services is required to pay per transaction. Checks should be made payable to Aspiring to Change Counseling Services.
Aspiring to Change Counseling Services accepts and processes insurance payments through a variety of insurance providers and Employee assistance plans. If you are using insurance or an employee assistance provider to pay for our services, then we will:
(1) Expect and accept payment of your copayment amount at the time of service;
(2) File your claim with the insurance provider
(3) Receive payment from your insurance provider
(4) Expect that you will pay your portion due of copay, co-insurance, deductible, or fee difference at the time of your appointment. PLEASE NOTE Aspiring to Change Counseling Services files insurance as a courtesy to you, and that you (not your insurance company) are ultimately responsible for your bill. If your insurance company denies a claim filed on your behalf, then you are responsible for paying Aspiring to Change Counseling Services for the difference between the standard rate and the amount previously paid as copay unless approved otherwise by owners of the Aspiring to Change Counseling Services. I agree to:
(2) give Aspiring to Change Counseling Services permission to release any information the insurance company may require in order to process payment; appoint Aspiring to Change Counseling Services as my authorized representative to act for me in obtaining payment.
(3) assign all of my rights to claims and payment by my insurance to Aspiring to Change Counseling Services, and
(4) agree to assist with the claims process as required by Aspiring to Change Counseling Services or my insurance provider. I understand that if my insurance plan requires that I meet a deductible amount prior to coverage by insurance, I will be responsible for the full session fee until the required deductible amount has been met. I acknowledge that not all issues, conditions, and problems dealt with in psychotherapy are reimbursed by insurance companies.
For Commercial insurances, all Explanation of Benefits received by practice will be billed to the client’s card on file on the Friday of each week received. Balances owed on accounts will charge the balance as stated on the EOB on Fridays of each week.
Private/Self-Payment for Services I will self-pay for services at Aspiring to Change Counseling Services. I agree to the fee schedule in this document. I understand that payment for services is due at the time services are provided.
Insurance carriers will not pay for late cancelations or missed appointments. Once an appointment is scheduled, that time is reserved specifically for you.
Cancelations must be made at least 24 hours in advance. Although 24 hours is the minimum, if you need to cancel or reschedule, please give as much notice as possible. You may notify our office of the cancellation by phone or email to your provider. Late cancelations (fewer than 24 hours before the appointment) will incur a fee of $35.00.
Amounts past due by more than 30 days will incur a late fee each month of $25.00. If your account has not been paid for more than 45 days and arrangements for payment have not been agreed upon, Aspiring to Change Counseling Services may resort to legal means to secure payment. This may involve hiring a collection agency, an attorney, or going through small claims court. If such legal action is necessary, you will be responsible for those costs.