Financial Policy / Fee Agreement
PURPOSE OF THIS AGREEMENT
This Financial Policy / Fee Agreement explains the financial policies and expectations associated with receiving counseling services from Ian Adams Therapy Services PLLC ("Practice"). Please read this agreement carefully and ask any questions you may have before signing.
By signing this agreement, you acknowledge that you understand and agree to the financial policies described below. This agreement should be read together with the Practice's Consent for Services, Notice of Privacy Practices, Payment Authorization, and any other applicable practice policies.
Fees For Services
The fees associated with counseling services, to the best knowledge of the Practice available at the time, will be communicated to you before or at the beginning of treatment. Your specific financial responsibility may depend on whether you are using insurance, your insurance benefits, your deductible, copayment, coinsurance, out-of-pocket maximum, authorization requirements, and other terms of your health plan.
When insurance is used, the Practice may submit claims to your insurance company as authorized. Insurance billing does not guarantee that your insurance company will pay for a particular service or that the amount paid by your insurance company will equal any estimate provided by the Practice.
You are ultimately responsible for charges that you are legally and contractually responsible for, including applicable copayments, coinsurance, deductibles, non-covered services, and other patient responsibility amounts.
Insurance Responsibility
If you plan to use health insurance to pay for counseling services, you are responsible for understanding the terms and limitations of your insurance policy.
Before beginning treatment, you are encouraged to contact your insurance company and confirm:
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That mental health/counseling services are covered under your plan;
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That Ian Adams Therapy Services PLLC and Ian Adams, M.S., LMHC are eligible to provide services under your plan;
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Whether the Practice is considered in-network or out-of-network;
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Your deductible and how much of it has been met;
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Your copayment or coinsurance responsibility;
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Whether prior authorization or other approval is required;
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Any limitations on the number or type of behavioral health services covered; and
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Any other requirements that could affect your financial responsibility.
The Practice may assist with insurance billing and may provide information available to us regarding your benefits. However, verification of benefits is not a guarantee of payment. Your insurance company determines whether a service is covered and what portion of the charge is your responsibility.
You are encouraged to contact your insurance company directly if you have questions about your benefits or expected costs.
Payment Responsibility
Any balance that is determined to be your responsibility is due according to the Practice's billing procedures.
Insurance claims may take time to process. Your account may therefore show a balance after an insurance claim has been processed, adjusted, denied, or otherwise finalized.
If you believe an insurance claim was processed incorrectly, please contact the Practice promptly so that we can review the issue with you. You may also need to contact your insurance company directly regarding an insurance determination or appeal.
You are responsible for keeping your insurance information current and notifying the Practice of changes to your insurance coverage.
Payment Method and Card on File
The Practice may require a valid payment method to be maintained on file through the Practice's electronic payment system.
By completing the separate Payment Authorization Form, you authorize Ian Adams Therapy Services PLLC to charge your card on file for amounts that are properly due under this Fee Agreement and the Payment Authorization.
This may include, as applicable:
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Copayments;
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Coinsurance;
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Deductibles;
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Unpaid balances;
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Missed-appointment or late-rescheduling fees;
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Other patient-responsibility amounts; and
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Other charges that you have authorized under applicable Practice policies or agreements.
For amounts covered by the Payment Authorization, the Practice may process the applicable charge without providing an additional notice before each individual charge.
The Payment Authorization is separate from this Fee Agreement and governs the specific authorization provided for use of the payment method.
If you believe a charge is incorrect, please contact the Practice promptly so that the account can be reviewed.
Cancellations and Rescheduling
At least 24 hours' notice is required to cancel or reschedule a scheduled appointment.
If you cancel or reschedule with less than 24 hours' notice, or fail to attend a scheduled appointment, a $90 missed-appointment/late-rescheduling fee may be charged.
The $90 fee is intended to compensate the Practice for reserved appointment time that cannot reasonably be offered to another client.
The Practice may waive or reduce this fee when appropriate, including when circumstances outside the client's reasonable control make timely cancellation or attendance impracticable. Waivers are determined on a case-by-case basis and are not guaranteed.
The missed-appointment/late-rescheduling fee may be charged to the card on file pursuant to the separate Payment Authorization without additional notice.
Insurance and payer restrictions
The missed-appointment/late-rescheduling fee will be charged only to the extent permitted by applicable law, insurance requirements, Medicaid/MCO requirements, payer contracts, and other applicable rules. If a payer prohibits or restricts charging this fee to a particular client, the Practice will follow the applicable payer requirements.
Unpaid Balances
If a balance remains unpaid, the Practice may attempt to collect the balance using the payment method authorized on the Payment Authorization form.
The Practice may also contact you regarding an outstanding balance and may discuss available payment arrangements.
If an account remains unpaid, the Practice may take additional collection action as permitted by law and applicable payer requirements.
The Practice will not use this policy to collect amounts that are prohibited from being collected from the client under applicable law, insurance requirements, Medicaid/MCO rules, or contractual obligations.
Financial Hardship and Payment Plans
If you are experiencing financial difficulty, please contact the Practice as soon as possible rather than allowing a balance to accumulate.
You are welcome to discuss:
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A payment plan;
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A modified payment schedule;
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Strategies for addressing an outstanding balance;
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Insurance billing or claim questions; or
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Other options that may be available based on your circumstances.
Payment plans or other arrangements must be agreed upon by the Practice and client in advance. An informal discussion about financial difficulty does not automatically suspend an outstanding balance or payment obligation.
The Practice will make reasonable efforts to work with clients experiencing financial challenges, but cannot guarantee that a particular payment arrangement or fee reduction will be available.
Refunds and Overpayments
If an account has been overpaid or an insurance payment results in a credit balance, the Practice will handle the credit in accordance with applicable law, insurance requirements, and Practice procedures.
If you believe your account contains an error or that you are owed a refund, please contact the Practice.
Self-Pay and Uninsured Clients
If you do not have insurance, or if you choose not to use your insurance for services, you may be responsible for the applicable self-pay fee.
When required by federal law, the Practice will provide a Good Faith Estimate of expected charges for uninsured or self-pay services. Federal law generally provides uninsured or self-pay individuals with the right to receive an estimate of expected charges when applicable.
A Good Faith Estimate is an estimate of expected charges and is not a guarantee of the final amount that will be charged. Additional services or circumstances that could not reasonably be anticipated at the time of the estimate may affect the final amount.
If you receive a Good Faith Estimate and believe your final bill substantially exceeds the estimate, federal law may provide a process for disputing the bill under certain circumstances.
Changes in Fees or Financial Policies
The Practice may change its fees or financial policies when necessary. When a change materially affects your financial responsibility, the Practice will provide appropriate notice.
Changes will not retroactively alter charges that have already been incurred unless otherwise required by law, payer requirements, or an applicable agreement.
Legal Matters, Court Appearances, and Forensic Services
Ian Adams Therapy Services PLLC provides clinical mental health services and does not routinely provide forensic, legal, or expert-witness services.
Treatment is intended to address the client's clinical needs and is not intended to provide legal opinions, advocacy for either party in a legal matter, or forensic evaluation.
Clients should understand that involvement in legal proceedings can require time and services outside of ordinary psychotherapy. Examples include, but are not limited to:
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Responding to attorneys, courts, or other legal representatives;
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Reviewing subpoenas, court orders, releases, or other legal documents;
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Reviewing or preparing records for legal proceedings;
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Preparing for a deposition or court appearance;
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Depositions;
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Testimony at hearings or trials;
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Expert-witness services;
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Consultation with attorneys regarding a client's treatment or records;
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Written statements, affidavits, declarations, or other documents prepared specifically for a legal proceeding;
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Travel or waiting time associated with a legal proceeding; and
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Other services specifically requested in connection with a legal matter.
Separate Fees for Legal or Forensic Services
Legal, forensic, deposition, testimony, court-appearance, consultation, record-review, preparation, and related services are not included in ordinary psychotherapy fees or insurance-billed psychotherapy services.
When Ian Adams Therapy Services PLLC agrees to provide such services, or when such services are otherwise required by applicable legal process, the following fee schedule will apply to the extent permitted by applicable law, court rules, subpoena requirements, payer requirements, and other applicable regulations:
Legal/forensic services: $400 per hour, billed in 15-minute increments.
This rate may apply to time spent preparing for, reviewing materials related to, consulting about, or participating in a legal proceeding, including deposition or testimony preparation and communication with attorneys or other legal representatives.
Court and Testimony Minimum
Any in-person or remote court appearance, hearing, trial testimony, deposition, or other proceeding requiring the clinician's scheduled participation will be subject to a minimum fee of $3,000 per proceeding, unless a different arrangement is required by applicable law, court order, subpoena, payer requirement, or other binding authority.
The $3,000 minimum is intended to account for the clinician's reserved professional time, preparation, and loss of availability for clinical appointments associated with the proceeding.
If the actual applicable charges under the $400-per-hour rate exceed the $3,000 minimum, the additional time may be billed at the $400-per-hour rate in 15-minute increments.
Cancellation or Rescheduling of Legal Proceedings
If a deposition, hearing, trial, court appearance, consultation, or other legal appointment is canceled or rescheduled after time has been reserved for the clinician, the client may be responsible for fees associated with the reserved time and preparation, subject to applicable law and any requirements imposed by the court, subpoena, payer, or other applicable authority.
Unless otherwise required by law or court order, cancellation or rescheduling of a legal proceeding with less than 24 hours' notice may result in a cancellation fee based on the amount of professional time reserved or otherwise committed, calculated at $400 per hour in 15-minute increments, subject to the applicable minimum described above.
If a legal proceeding is canceled or rescheduled with sufficient notice, the Practice may still charge for professional time already spent preparing for or otherwise providing services related to the proceeding.
Advance Payment and Payment Arrangements
Because legal and forensic services may involve substantial time outside of ordinary clinical appointments, the Practice may require payment or a deposit before providing or reserving legal or forensic services.
The Practice may require an advance payment sufficient to cover anticipated services, including the applicable $3,000 minimum for a court appearance, before agreeing to reserve time for a proceeding.
Any advance payment will be applied to charges actually incurred, and any remaining balance or credit will be handled in accordance with applicable law and the terms of the payment arrangement.
Insurance
Legal, forensic, deposition, testimony, court-appearance, attorney-consultation, and similar services are generally separate from ordinary psychotherapy treatment and may not be covered by health insurance.
The client is responsible for understanding whether any requested legal or forensic service is covered by a particular insurance plan. The Practice will not represent that insurance will cover these services unless coverage has been specifically confirmed.
Subpoenas and Legal Requirements
Nothing in this Fee Agreement is intended to prevent a court, governmental agency, or other legally authorized entity from exercising its lawful authority.
If the Practice or clinician receives a subpoena, court order, or other legal demand involving a client, the Practice will respond in accordance with applicable law and professional obligations.
A client's request that the clinician not disclose information, or a client's refusal to pay a fee, does not necessarily prevent disclosure or participation when disclosure or participation is legally required.
Where permitted, the Practice may seek clarification, modification, or other appropriate relief from a subpoena or legal demand before providing records or testimony.
Clinical Role and Legal Proceedings
If the clinician participates in a legal proceeding concerning a current or former client, the clinician's role remains subject to applicable professional and ethical requirements.
The clinician may distinguish between:
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Clinical observations and information obtained in the course of treatment; and
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Opinions or conclusions that would require a separate forensic evaluation or expertise beyond the clinician's treatment relationship.
The clinician does not guarantee that testimony, records, or other information provided in connection with a legal proceeding will support a client's position or desired outcome.
No Guarantee of Availability
Because court proceedings and legal matters can interfere with scheduled clinical services, the Practice does not guarantee availability for a particular date, proceeding, deposition, hearing, or trial.
The clinician may determine whether to voluntarily participate in a legal matter based on clinical, ethical, professional, scheduling, and other applicable considerations.
Nothing in this section limits any obligation imposed by a valid subpoena, court order, or other applicable legal authority.
Please contact the Practice promptly if you believe there is an error in your account or if you are having difficulty paying a balance.