PATIENT STATEMENT OF UNDERSTANDING

The choice to begin treatment is an important decision. Thank you for placing your confidence in BWG and your provider. In order to facilitate the process, we have created some guidelines below. Please note that in our commitment to assisting you with your treatment goals, we welcome open discussion about your treatment and progress throughout  this process. 

 

PROCEDURES: 

     INITIAL APPOINTMENTS: Initial appointments range from 60 to 120 minutes depending on the provider. 

     FOLLOW-UP APPOINTMENTS: Follow-up appointments range from 15 to 45 minutes.  

  • New patient (including Self pay) $310.00 - $450.00
  • Follow-up (including Self pay) $200.00 - $330.00
  • No Show/Late Cancel Fee $40.00 - $95.00 
  • Paperwork Fee (depending on length/time) $25.00 - $50.00 


NO SHOWS/LATE CANCELLATIONS: 

*A full 24 business hours’ notice is required for cancellations* 

Payments for late cancels/no-shows will be expected at or before the next scheduled appointment. If you have an emergency and must cancel, please speak with your prescriber directly about the possibility of negating the charge prior to the cancellation. THE PATIENT, NOT THE INSURANCE COMPANY, WILL BE RESPONSIBLE FOR PAYING FOR APPOINTMENTS CANCELED WITH LESS THAN 24 BUSINESS HOURS NOTICE. By signing this Patient Statement of Understanding, you agree to pay for any missed appointments via check or credit card. 

 

EMERGENCIES: For extreme emergencies such as: self-destructive intent, alcohol or drug intoxication, severe medication reactions or loss of contact with reality, call 911 or go to the nearest emergency room immediately. 

 

“PRIVATE PAY” PATIENTS: Fees are generally based upon the length of time of a session.  While some insurance companies reimburse the patient for psychiatric care, the payment of the bill is the patient’s responsibility. Please make full payment at the time of each appointment. If you have insurance that will reimburse you, submit a copy of your receipt and bill to the insurance company for reimbursement. 

 

PAYMENTS / “CONTRACTED” INSURANCE: If we are a contracted provider with your insurance carrier, BWG staff will submit the charges for services and accept payment by that company. Any self-pay, contracted deductible, co-payment, coinsurance or partial payment that is the insured’s responsibility will be collected at the time of service.

 

BILLING: For billing issues, contact Kathy Long at katlong@behavioralwellnessgroup.com. 

 

CONFIDENTIALITY: Your accumulated medical records are confidential except under special legal circumstances. Information contained in them will not be released to anyone without written consent from you, the patient. Please ask me if you have any questions. 

 

TERMINATION OF CARE: Termination of care may occur by mutual consent, completion of treatment, or for your failure to keep your appointments or pay for services. If you do not contact your prescriber for more than three months and make no follow-up appointments, your care will be terminated unless you have made verbal arrangements for continuation of  your treatment with your BWG prescriber. 

 

CONFIDENTIALITY: To protect your confidentiality, if our paths cross outside of this office, I will not initiate contact with you.