If Patient is a Minor, Who is Legally Responsible for Charges Incurred?

I hereby authorize Central Behavioral Healthcare, Inc. to furnish complete information regarding services rendered and to bill my insurance company for all services. I authorize payment of benefits directly to Central Behavioral Healthcare, Inc. I understand, however, that payments for these services are my own responsibility, If private pay, my signature below represents my responsibility to fulfill this obligation. Billing of your insurance company is a courtesy to you. You are responsible for knowing your insurance benefits and limits. (co-payment, number of visits).

CENTRAL BEHAVIORAL HEALTHCARE, INC. CONFIDENTIAL HANDLING INSTRUCTIONS I WISH TO BE CONTACTED IN THE FOLLOWING MANNER (CHECK ALL THAT APPLY)

Oral Communications

Acknowledgement of Receipt of “Notice of Psychologist” Policies and Practices to Protect the Privacy of Your Health Information (upon request) The federal government mandated that as of April 14, 2003 all health care patients are to receive from their clinicians a notice regarding the protection of their private health care information in compliance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule (45 C.F.R. parts 160 and 164). This acknowledgement documents that you have received the “Notice” that is required. HIPAA covers what is called “Protected Health Information” (PHI) that is used for treatment, payment, and health care operations. PHI is information in your health record that could identify you. The notice contains basic information about: 1. How your PHI may be used and disclosed for treatment, payment and health care operations. 2. Which uses and disclosures require authorization from you and which do not? 3. How you may revoke an authorization you may have signed 4. Certain rights you have to restrict use and disclosure of PHI, to receive confidential communications by alternative means and at alternative locations, to inspect and copy your records, to amend your records, to have an accounting of Disclosures. 5. A list of my duties to protect the privacy of your PHI, my right to change the privacy policies and practices described in the Notice. 6. What you can do if you have any complaints about violations of your privacy rights, about decisions about your access to your records I may make. 8. Any restrictions and limitations you or I wish to put on the use and disclosure of your PHI. The Privacy Notice is a few pages in length. Generally, this Notice is given on a patient’s first visit. A copy of the Notice is available upon request. I acknowledge that I have read the above information and can request a copy of the Privacy Notice (version dated April 1, 2003) as required by the federal government’s HIPAA legislation.

Central Behavioral Healthcare, Inc. Financial Policy We are dedicated to providing the best possible care for you, and we want you to completely understand our financial policies. 1. Payment is due at the time of service unless arrangements have been made in advance. (We accept American Express, Discover ,MasterCard ,Visa and Debit) 2. Your insurance policy is basically a contract between you and your insurance company. As a courtesy to you, we will file your insurance claim and the benefits will be paid directly to Central Behavioral Healthcare. If your insurance company does not pay the practice within a reasonable period, (3 months) we will have to look to you for payment. If we later receive a check from your insurer, we will refund any overpayment to you. 3. We have made prior arrangements with many insurance companies and other health plans to accept an assignment of benefits. We will bill them, and if you are required to pay a co payment or if you have a deductible to meet, payment is expected at the time of your visit. (unless other arrangements are made) 4. If you are insured by a plan that we are not in network with, we will send the claim for you on an out of network basis. This means the insurer may send the payment directly to you. Therefore, our charges for your care are due at the time of service. 5. Not all insurance plans cover all services. In the event your insurance plan determine a service to be “not covered,” you will be responsible for the complete charge. Payment is due upon receipt of a billing statement from our office. 6. Please be aware that you as a patient are responsible for knowing what type of insurance coverage you have, if the therapist you are seeing is a participating provider, the amount of your co payment or deductible and if a referral is a needed prior to visit. If you have an insurance question regarding your specific plan, please call your insurance company directly. I have read and understand the practice’s financial policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time.

FEES: Our current fee is $200 per session. The initial session is $225. Court-related cases are $250 per session, and court testimony and travel time is $330 per hour. The duration of a session ranges from 45-60 minutes. Payment arrangements will be determined at the time of your first visit. Any changes in this agreement must be approved by CBH. OTHER CHARGES: We will charge for phone calls or preparation of insurance claims only if they become too time consuming. We will inform you of any such charges. Any service provided under subpoena will be charged at court testimony rates. When physical tests are administered, or if reports of any kind are prepared for another party or you, there will be an additional charge. If you are not sure if this applies to you, please ask your therapist. There will be a $35 charge for returned checks. A finance charge of 1.5% per month will be calculated on all balances over 90 days due. MISSED & CANCELLED APPOINTMENTS: Missed appointments and cancellations less than 24 hours prior to the scheduled appointment may result in a charge for that time. CBH maintains 24 hour voicemail and a message is sufficient notice during times when the office is closed. FAILURE TO PAY YOUR BILL: Financial hardships may occur to any of us. These hardships should be discussed with your therapist, so that necessary changes in your payment agreement can be made. Non-payment may result in collection efforts or legal actions. This is a regrettable action used only when other efforts have failed. If an account is sent to collection, you will be held financially responsible for all ordinary collection fees assessed to CBH. CONFIDENTIALITY:Information revealed in your session is confidential and will not be released to others without your permission. There are some routine exceptions to this policy. If you were referred by your physician for a consultation, we usually send information back to your physician so your complete physical and mental health can be coordinated. If your health insurance is a managed care program, we are required to provide information to them so payment for services rendered can be approved. If you have concerns about this information, please discuss it with your therapist. Some legally required exceptions to confidentiality include situations of potential harm to oneself or others, incidents of child abuse (Ohio has mandatory child abuse reporting law) and instances where a court may order records.

Payment Agreement

As a client of Central Behavioral Healthcare, Inc., I understand that I am financially responsible for professional services received by me or those for whom I am responsible. It is my intention to carry out my financial responsibility to CBH in the following manner: