CANCELLATIONS AND NO-SHOW POLICY

Once your appointment is scheduled, you will be expected to pay for it unless you provide at least 24 hours advance notice of cancellation. Business hours are considered the weekdays between Monday and Friday, during the hours of 8 am and 5 pm. This means that if you have an appointment on Monday January 7th at 4 pm, you must cancel by 4pm Friday January 4th to avoid being charged. If you do not provide at least 24 business hours notice, or fail to show for a scheduled appointment, you will be responsible for up to the full cost of the session. This includes group sessions. Please note, insurance companies will often not reimburse for missed sessions or sessions that are cancelled late. YOU WILL NOT BE SEEN FOR FUTURE SESSIONS UNTIL THE BALANCE HAS BEEN PAID. ACCORDING TO CHAPTER 12, SECTION 30.3.13 OF MEDICARE CLAIMS PROCESSING MANUAL, WHICH IS ATTACHED TO CHARGE REQUEST 5613(CR5613), CMS’S POLICY IS TO ALLOW PHYSICIANS AND SUPPLIERS TO CHARGE MEDICARE AND NON-MEDICARE BENEFICIARIES FOR MISSED APPOINTMENTS.

BILLING AND PAYMENTS:

All collected payments are collected at time of visit. A signature acknowledges the service was received and therefore acknowledges waiver of the right to dispute these charges. For any dispute, a person has 7 days to dispute this charge and at that time, your signature on the treatment consent acknowledges you’re waiving the right to dispute charges beyond this time and acknowledge your bank has no obligation to return the funds. Further, you’re accepting if a dispute is initiated, there is a charge for professional time spent responding to the dispute. For patients with blue cross blue shield, checks will be mailed directly to the patient and the check must be brought in within 30 days of it being mailed. At the provider’s discretion, no refills or future appointments will take place until the payments are collected. If payments exceed a certain amount, you may be taken to small claims court / sent to collections in effort to obtain balance owed. Please see insurance and reimbursements for more information related to billing and insurance payment. A $75 fee will be charged to any credit card charge that is disputed for administrative time required to respond to dispute.

INSURANCE AND REIMBURSEMENT

We are considered an “OUT OF NETWORK” practice, for all major insurance plans except Medicare. My staff will gladly look into your out of network benefits to see if our services will be covered. Most major insurance plans have out of network benefits. If you have a health benefits policy, especially a PPO, it will usually provide some coverage (example 60% or 80% of coverage). You are responsible for the balance. Please speak to me directly about this should you have any questions. Should you not have out of network benefits, I would gladly work out a payment plan to best accommodate your financial situation. By signing the

treatment consent, you are acknowledging that, in accordance to NJ P.L. 2018, c. 32, you have made me aware, in writing, prior to the provision of any services as well as at the time of your appointment, that we are OUT OF NETWORK. You acknowledge that we have informed you of: the amount, or estimated amount, the health care professional will bill for the procedure is available upon request; that upon request, disclose to the covered person in writing the amount or estimated amount that will be billed for the procedure and the associated Current

Procedural Terminology (CPT) codes for the service; that we have Informed you that you will be financially responsible for services provided out-of network in excess of copayment, deductible, or coinsurance (referred to as balance billing) and that he or she may be responsible for costs in excess of those allowed by a health benefits plan; and; we advised you to contact their health benefits plan for consultation on costs. Please be aware that most insurance agreements require you to authorize me to provide a clinical diagnosis, and sometimes additional clinical information, such as a treatment plan summary, or in rare cases, a copy of the entire record. We are required to submit this information on your behalf if you choose to obtain insurance reimbursement.

TELEMEDICINE

I acknowledge that if my insurance does not cover telemedicine visits, I will be held financially responsible for payment for these visits. See attached for further information on telemedicine / Tele-therapy.

SUMMARY OF MEDICAL ACCEPTANCE POLICY

North Jersey Health and Wellness does participate in Medicare.

PROFESSIONAL RECORDS

Both the law and the standards of our profession require that I keep appropriate treatment records. You are entitled to review a copy of the records, unless I believe seeing them would be emotionally damaging, in which case, I will be happy to provide them to an appropriate mental health professional of your choice. Because these are professional records, they can be misinterpreted or upsetting, so I recommend that I review them together with you so that I can discuss what they contain. I can also prepare an appropriate summary for review. Clients will be charged an appropriate fee for any preparation time that is require to comply with any information request. Records will not be released if there is an outstanding account balance until the balance is paid in full.

CONFIDENTIALITY

Confidentiality is the cornerstone of mental health treatment and is protected by the law. I can only release information about our work to others with your written permission. Some basic information about diagnosis and treatment may be required as a condition of your insurance coverage. Exceptions to confidentiality where disclosure is required by law:

• If there is a threat of serious bodily harm to others, I am required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization.
• If there is threat to harm yourself, I am require to seek hospitalization for the client, or to contact family members or others who can help provide protection
• If there is an indication of abuse to a child, an elderly person, or a disabled person, even if it is about a party other than yourself, I must file a report with the appropriate state agency.
• If you are involved in judicial proceedings, you have the right to prevent me from providing information about your treatment. However, there are some circumstances in which your emotional condition is an important element, and a judge may require my testimony.

If due to mental illness, you are unable to meet your basic needs such as clothing, food, and shelter, I may disclose information in order to access services to provide for your basic needs. If I feel you are in acute danger to yourself or others, I am required to take appropriate action and to contact appropriate parties involved.

These situations have rarely arisen in my clinical practice, but should such situation occur, I will make every effort to fully discuss it with you before taking any action. I may occasionally find it helpful to consult with other professionals. In these circumstances, I will make every effort to avoid revealing the identity of you as my patient. The consultant is also legally bound to keep the information confidential. Confidentiality is waived if there are any disputes of charges if documentation is necessary to show proof of service or in situations in which we have been unable to receive payment for service and have to pursue legal measures. You also acknowledge that you allow us to contact you via text message or voice messaging to remind you of your appointments. If you do not wish to be contacted, you will need to specify this in writing and let us know directly, otherwise we will use the number you provide to contact you.

As it is our philosophy to provide a collaborative, comprehensive care model, patients may be referred to see multiple providers within the office. By signing our treatment consent, you are consenting that you understand and give permission for collaboration between providers within NJHW through verbal, electronic, or paper communication. You also acknowledge that a covering or supervising provider may also need access and if applicable, you consent to this as well. Certain supervision requirements are required at state and organizational levels and your consent also extends to the supervising party if applicable. Your signature also provides consent to allow us the right to speak to your other medical providers outside NJHW if it is regarding an issue that could urgently effect your health or well-being. This is our policy so that we can provide the safest and most comprehensive care to you. Your signature on our treatment consent acknowledges you’ve read and are in agreement with all of the above

CONTACTING CLINICIAN

Some of our clinicians choose to give their personal cell phone numbers to their patients. This being said, your signature acknowledges that you have been informed and are agreeing that the personal contact of the provider is not appropriate in case of an emergency. You’re acknowledging that in an emergency you will contact 911 or go to the nearest emergency room. You also acknowledge that contacting a clinician does not take the place of an actual appointment. The abuse of this privilege will result in the loss of this privilege and is at the provider’s discretion. You are acknowledging that this is a PERSONAL cell phone and the provider has no obligation to return communication and it is not to be treated as the primary line of communication in reaching the office / provider.