Financial Information

Financial Services Agreement v 1.2

Introduction:

We are dedicated to providing the best mental health care. We believe that your complete understanding of your financial responsibilities is an essential element of providing your care. As an adult, you are responsible for payment of services. For services rendered to minor patients, the parent(s) or guardian(s) of the minor are responsible for payment. The person who agrees to cover any expenses is called the “guarantor” and is designated before the patient is seen. For continuity of care, all staff at 4KidHelp, Inc. utilize a common electronic health record.  By joining the practice, you agree to the Financial Services Agreement.

Use of Credit or Debit Card

Financing health care is very complex. 4KidHelp and Adults participates in several insurance plans which are listed on our website. In general, there are 3 steps in you paying our bills with insurance:

• Step 1: The office collects your copay (which is often on your insurance card), your deductible, or your coinsurance (percentage of the charge which you owe).  We may also collect a deposit charge based on the estimated amount you will pay after the insurance company processes the claim.
• Step 2: We send the bill to your insurance company. They take a while to tell us how much the allowed charge can be (based on our contract with them) as well as what they pay.
• Step 3: We then bill you for the rest which is the allowed charge minus what you and the insurance company have paid so far.

This process requires a substantial amount of time.

We are now using a different system to collect payments for the services we provide. From this point forward every client of 4KidHelp and Adults will provide a credit card or debit card called an Authorized Payment Method (APM). This APM will be charged for all monies owed by the patient. If the patient is a minor child, the financially responsible adult will provide this information. We will keep the APM on file in a secure online vault which has bank level encryption.  Once in the vault, even our staff cannot access the details of your financial information. Patients or the financially responsible adult must tell 4KidHelp and Adults within 3 days of any changes to the APM. The APM system will also attempt to update the vault information by itself electronically. Charges will be made after the service has been provided. If you do not have insurance the full fee will be charged to your APM as listed below. The President or the Program Administrator of 4KidHelp and Adults may authorize exceptions to this policy.  If exempted, the patient may be required to pay their balance before they can schedule another appointment, get a refill or receive any service from 4KidHelp and Adults.

All insurance plans are “plan specific” and pay differently. It is the patients’ responsibility to know their plan benefits. As a courtesy, we will submit charges to insurance companies on whose panels we participate. You can find that list of insurance companies which we accept on our webpage. If your insurance is not on that list, you are responsible for full payment at the time of service. We can provide you with a receipt which you may use to seek reimbursement from your insurance company, depending on plan benefits.

If we contract with your insurance company, we will charge fees from Step 1 and Step 3 above to the APM, along with fees for other services not reimbursed by your insurance company (as permissible by law and in accordance with patient contracts). These fees are listed below.  You will receive a receipt in your email. If you would like a paper statement please call the office. You can track your charges through your insurance company’s EOBs (Explanation of Benefits).

• For questions about how much your insurance pays or has paid on charge(s) – your Insurance Company.
• For your account – our Billing Company, UnisLink, at 724-906-4808 ext. 62
• For the reason for a particular charge – our office, 4KidHelp and Adults, at 330-433-1300 or use our secure texting service through your phone.

We reserve the right to collect a deposit charge at the time of service for an estimate of what you will owe. This amount might be lower based upon payments made by your insurance company. If the final amount due is lower than the deposit for that service, then the balance will be refunded to the patient through their APM.

If a patient pays on-site with cash, check, credit card or debit card, they will receive an electronic receipt through email.  If you leave the practice or your case is closed, it can take several months to finally resolve your account. Any non-paid balance will be referred to a collection agency.

Charges for Services for Uninsured and Self Pay Patients

Out of pocket fees for patient sessions: If you are paying out of pocket and in keeping with the No Surprises Act, we are listing the cost of services.

1. For Therapists
   • Assessment: $250/hour
   • Therapy: $125/hour
2. For Psychiatric Providers
   • Assessment: $300/hour
   • Follow-up: $200/hour (billed in ½ hour increments)

Missed appointment fees: Please be aware, if an appointment is missed, canceled late, or you arrive too late to be seen, you will be charged directly as long as it is permitted by your insurance company. We have so many patients needing our service that a missed appointment effectively eliminates another patient from being seen earlier.

1. For therapists – $150
2. For Psychiatric Providers – $100 for every 30 minutes scheduled

Charges for Extra Services

4KidHelp and Adults values clear communication about all aspects of care including financial obligations. Unfortunately, insurance companies do not cover all costs of care. We will charge for services not covered by insurance as permissible by law and by the contract with your insurance company. These charges also apply for all self pay and uninsured patients.

1. Prescription refills outside of appointments- $25 for all medications
2. Filling out forms
   • 1 Page – $25
   • 2 or more Pages – $50 and up depending on length
3. Letters and Reports:
   • $100 for first page, $50 for each additional page
   • May have additional charge if it requires review of documents or communication about document outside of normal visit
4. School Medication Administration Forms – $25 total
5. Prior Authorization – $35/medication
6. Payments returned due to insufficient funds, or credit card being canceled or not updated – $40
7. Copy of medical record
   • Free copies
     1. Patient – first copy
     2. To other health care providers
   • Charged copies at the rate set by the Ohio Health Department’s annual schedule of copying charge fees
8. If there are other services not paid by your insurance, any extra fee will be negotiated before provided, giving you a chance to choose to proceed or not with that service.

Unbilled Services

1. Communication with the office through secure text, email, or phone unless patient is notified prior to the communication that there will be a charge.
2. Activities that occur during the patient appointment.
3. A copy of your medical record sent directly to another provider which has your written consent.
4. Prescription refills caused by provider cancellation of appointments, or planned when setting the next appointment.

Definitions

1. Missed Appointment: A missed appointment is one in which the patient doesn’t show up and has not notified 4KidHelp and Adults with enough notice that they are canceling the appointment.
2. Arriving late: If a patient shows up late to the appointment the patient may be charged. Showing up late is defined as follows:
   • For a 15-minute appointment: 8 or more minutes
   • For a 30-minute appointment: 15 or more minutes
   • For an appointment longer than 30 minutes: 20 or more minutes
3. Late Cancelation: To avoid being charged appointments not canceled prior to the appointment (for new patients must be 3 business days prior to the appointment; for existing patients must be within 24 business hours prior to the appointment). A “business day” is a day we are open – Monday, Tuesday, Wednesday, and Thursday. The office is closed on Fridays. E.g. a follow-up appointment on Monday must be canceled on the previous Thursday to avoid a late cancelation fee. A new appointment must be canceled by the previous Tuesday to avoid a late cancelation charge.
4. Refunds: We will return any monies over $10 to your APM along with an email receipt once all other charges are paid.

Any debt old or new is expected to be satisfied to continue services with 4KidHelp, Inc. We reserve the right to dismiss patients from 4KidHelp, Inc. for failure to comply with the terms of this Agreement, including, but not limited to, the failure to keep and/or bring your account current after having been notified of a delinquency. Should a dismissal be exercised, a patient will no longer be permitted to schedule appointments with 4KidHelp, Inc. 4KidHelp, Inc. will continue to provide urgent mental health care only through the thirty days following notice of dismissal to provide sufficient time during which to locate a new physician. Upon dismissal, you may contact our office to obtain authorization forms to transfer your records to another physician. You may be charged a fee for processing these records; the fee must be paid up front.