Willow Ann Rose LPC CHT ~ SpiritWell
South Eugene Wellness Center~Tamarack Building
3575 Donald St. ~ Ste 115
Eugene, Oregon 97405
Phone: 541 461-5424
willowrose@spirit-well.com


FINANCIAL AGREEMENT

By agreeing to enter into therapeutic work with Willow Ann Rose LPC CHT, we have begun a professional relationship that includes your agreement to certain financial obligations. In an effort to reduce any misunderstandings or difficulties in our work together, I welcome at any time, your questions and comments regarding my financial policies.

SESSION FEES
Current Fee for Most Psychotherapeutic Services:
$140.00 per 50-Minute Session.

Fee for Initial, 55 Minute Insurance Evaluation is $170.00.

Each fifty-minute session includes time for payment and scheduling of your next appointment. Occasionally my hourly fee must be raised to cover increased business expenses. I will provide a minimum of one-month notice prior to any increase.

REDUCED FEE OR NO INSURANCE FEE
(Payable on day of session/ no insurance billing required).
Reduced Fee for a 50- Minute Psychotherapy Session: $125.00.

Please ask if other arrangements are needed.
Fees will be discussed in advance prior to your agreement and signature added to the last page of this Financial Agreement.

Groups, workshops and fees for some specific modalities vary. Occasionally, my Reduced Fee Payment structure must be raised to cover increased expenses. I will provide a minimum of one-month notice prior to any increase.

FOR ALL CLIENTS
Our agreed upon session fee will also apply on a prorated basis for phone calls, case management, letter writing or correspondence requests requiring 15 minutes or more.

Please Note:
Insurance plans will not reimburse for therapist’s time spent in completing correspondence, case management or for sessions lasting longer than 55 Minutes. Also, some Insurance plans do limit sessions to no longer than 45 Minutes long. I am happy to discuss how this might affect our work.

Full payment is expected at the time of session unless previous arrangements have been made. If you are utilizing an Insurance plan I can accept, your copay, coinsurance or payment toward unmet deductible is expected at the time of your session.

IN OFFICE, I ONLY ACCEPT PAYMENT VIA CASH (exact amount), OR PERSONAL CHECK.
A $30 charge will be added to any check that is returned or needs to be re-submitted due to insufficient funds.
Please make checks out to “Willow Rose”

If you prefer to pay via credit or debit card, (some HSA Cards) for your convenience, a PAYPAL button is available on each page of my website. If you choose to use this form of payment, it is still expected that you will reimburse the same day of your appointment.

CANCELLATION
Cancellation 48 Hours prior to a scheduled session is preferred. Cancellation Notice must be made a Minimum of 24 hours before a scheduled session to avoid being charged for the missed session.

(Some modalities have different cancellation policies, which will be discussed at time of scheduling those sessions).

Sudden/contagious illness, emergency situations or inclement weather are exceptions to this missed session charge.
This includes current COVID Health Screening Guidelines.
(If COVID Health Guidelines are still in force at time of our session, they will be made available to you prior to our initial scheduling).

If you need to cancel a session:
A voicemail message may be left on my Office phone (541 461-5424) at any time.
NOTE: MY OFFICE PHONE DOES NOT ACCEPT TEXTS

OR
Email: willowrose@spirit-well.com
Email will often reach me more quickly than a phone message.

If you have not contacted me or arrived by 15 minutes past the start of our scheduled session time, I will assume you will not attend the session and I will utilize the remainder of the hour at my discretion; know that I may not be available if you arrive later than 15 minutes past our scheduled start time.

As a courtesy to the next scheduled client, if you arrive late for your session, note that our session will still end at the scheduled completion time. Remember that our 50 Minute session period includes business matters such as paying for your session and scheduling the next appointment.

If I need to cancel a session, I will make every effort to contact you as soon as possible. In order to assist me in reaching you, please ensure I always have your current phone and email information.

LATE CANCELLATION FEES
AS I CANNOT BILL INSURANCE FOR YOUR CANCELLATIONS OR NO SHOWS, YOU WILL BE PERSONALLY RESPONSIBLE FOR THE FOLLOWING:

“MISSED SESSION CHARGES”.

THESE GUIDELINES APPLY TO BOTH INSURANCE AND “REDUCED FEE” CLIENTS.

For first missed session without minimum 24 hours notice:
Charge is $50.00

For the second missed session without 24 hours notice:
Charge is $100.00.

IF YOU HAVE NO-SHOWED OR LATE-CANCELLED TWICE, AND HAVE NOT REIMBURSED ME FOR THE LATE CANCELATION FEES I WILL ASK THAT YOU PAY IN ADVANCE PRIOR TO SCHEDULING YOUR NEXT SESSION.

Insurance Involvement in Your Care
Insurance billing requires that I provide at minimum, a specific mental health diagnosis and date of onset of symptoms in order to bill for your services. Though less usual, I may also be required to provide a full mental health assessment, specific treatment goals, including a detailed plan of care and other information. If this information is requested by your insurance company, I will notify you that the request has been made.

Some of the services I provide may not be reimbursed by your insurance provider. Your provider is unlikely to pay for the longer sessions needed for some modalities. If we determine modalities other than Psychotherapy may be of benefit, I am happy to discuss financial arrangements with you if needed.

Before you sign this agreement, we will have discussed if I am “in network” for your particular insurance plan. At any time, I can provide you a list of Insurance plans for which I am currently “On Panel.” I cannot guarantee I will continue to be a provider for any particular insurance plan. I cannot guarantee any particular plan will continue to accept me as a Provider.

If I am not currently a Preferred Provider you may contact and ask if your plan will accept you paying me directly for services. Afterwards, I provide you a “Super Bill” which you in turn will submit to your plan to receive some percentage of reimbursement returned directly to you.


Please identify if you will be asking for a “Super Bill” prior to signing this Form and attending our first session.

CLIENT RESPONSIBILITY

PRIOR TO OUR FIRST SESSION:

Contact your insurance provider to clarify if:

My services are supported by your own particular insurance plan

Determine if pre-authorization is required.

Confirm that you have fulfilled your deductible for the current benefit year or the amount of deductible still owing,

Confirm your copay or co-insurance amount due at each session.

If you have an outstanding deductible,

you must pay for your sessions directly until this deductible is met. I am not able to receive reimbursement of any kind from your insurance company until you have fulfilled all deductibles. Please ask if you need accommodation in fulfilling your deductible.

If you suddenly lose your insurance, you know your insurance plan will be changing or your insurance plan has changed to one I cannot accept, NOTIFY ME IMMEADATELY so that we can make other financial arrangements to continue/complete our work.

BRING TO OUR FIRST SESSION:

*Your insurance membership card so that I can make a copy,
(or your own copy of both sides of card).

*If our session is via phone or teletherapy, you may take a photo or scan both sides of your insurance card and email to me prior to our session:
willowrose@spirit-well.com
or promptly postal mail to me to ensure I have in office at our session.

*For Insurance Clients: I must have proof of your Insurance Plan Card at our first session.

*Also bring, email or postal mail for initial session:

Any Pre-Authorization paperwork if required.

*Copay/co-insurance or deductible fees or PayPal fee paid beforehand. (Reminder: cash or check only in office)

*If we have previously discussed and agreed to Private Pay Fees, your Check (made out to Willow Rose), cash, or Payment Made via PayPal.

*Also Bring (If not already completed electronically and emailed to me:
Your completed Client Questionnaire
Financial Agreement
Consent to Treat
Acknowledgment of COVID Guidelines



Willow Ann Rose LPC CHT ~ SpiritWell
South Eugene Wellness Center~Tamarack Building
3575 Donald St. ~ Ste 115
Eugene, Oregon 97405
Phone: 541 461-5424
willowrose@spirit-well.com


TO BE COMPLETED AT FIRST SESSION OR ELECTRONICALLY SIGNED AND SUBMITTED PRIOR TO FRST SESSION: I affirm I have read this Financial Agreement document and before signing, have discussed any questions I might have with Willow Rose LPC CHT. I accept responsibility for all fees and charges as outlined in this document and agreement. I understand that at any time, I am welcome to discuss with Willow Ann Rose LPC CHT, any concerns that may arise regarding our work together and this agreement.

I have been provided a copy of this agreement.
I understand, additional Information is available via the
Professional Disclosures Document (Available on Website),
which I have read, prior to our first meeting.
*Insurance Plan Name   
*CoPay or Co-Insurance % Due at Each Session   
*(If Agreed) Reduced Fee/Cash Fee Due At Each Session   
*Client Signature    *Today's Date
* Full Printed Name: * Email:


You will receive an email of your consent form. Please be sure your email address is correct above.



Form Revised July 2020