Acquire Mental Health Fee Agreement

INSURANCE. 

In most cases, we will bill your insurance company directly. It carries no guarantee of payment. There are various reasons an insurance company may deny a claim, and in those cases, you are responsible for the charge. You may call your insurance company to check your benefits, but this also does not guarantee payment. Most insurance plans do not cover 100% of charges. You may receive a bill due to a deductible, a co-pay, or because of termination of your coverage. You are responsible for the balance due. Bills can be paid in person, online, via phone, or via mail. Please note billing is done under Jennifer Vaughn Therapy Services LLC DBA Acquire Mental Health.

OUT OF NETWORK AND OTHER VENDOR PAYMENTS

If we are out of network with your insurance OR if you have a third-party paying you bill (crimes victims reparation, workman's comp, co-op insurance), you will be expected to pay our billable (not discounted) rate, and we will give you a detailed receipt for possible reimbursement from the third-party or out of network insurance.

*CASH ACCOUNTS (Date of Service)

Clients who do not have insurance, or do not want to use their insurance may pay Date of Service rate. Clients who pay via DOS receive a discounted rate as payment is due at the time of check in.

BOUNCED CHECKS AND DECLINED CARDS

If a check bounces, you will be responsible for all the fees incurred due to the bounced check, plus what your originally owed. If your card is declined, we will attempt to charge the card again in a few days. If it is still declined, office staff will contact you. If for some reason a charge gets “bounced back” you will be charged the original fee, plus any fees incurred.   

THIRD PARTY BILLING AND BILLING STATEMENTS

Jennifer Vaughn Therapy Services LLC DBA Acquire Mental Health uses Tebra/Medibillpros for billing and Stripe for credit card processing. By signing below, I authorize any release of information to process my payment. If you have any questions, please contact us at 218-820-6626. Statements go out monthly, around the 9th of the month. These are due upon receipt, and payments will need to be up to date to continue to schedule with your provider. You will also receive text reminders on the 9th and 27th of the month. You may "opt out" of these.

 ACCOUNT LIABILITY AND NON PAYMENT

I am ultimately responsible for my account balance. If my bill is not paid within 30 days, office staff will contact me to secure payment or a payment plan. If a payment plan is not made, and/or payments have not been received past 60 days, I will receive a letter and my sessions will be paused. If I still have not paid my bill in 90 days, my bill may be sent to collections. Jennifer Vaughn Therapy Services LLC (DBA Acquire Mental Health) is allowed to release information in order to receive payment for services. If your balance accrues to $300, we will discuss options, so that your balance does not become insurmountable.

GOOD FAITH ESTIMATE: Please note, fees increase yearly. Codes most used in italics

Assessments:

Intake/Diagnostic Assessment (90791 code): Billable rate: $350, DOS/Discounted rate: $200

Extended DA or Comprehensive assessments (90791 TG code): EI: Integrative assessments, DC 0-5 assessments, complicated assessments with collateral contact: Billable rate: $500, DOS/Discounted: $300

ADHD/Autism Assessments (90791 TG Code plus testing: Billable Rate: 90791 ($500), 96127 (testing codes): $50 a test. DOS/Discounted rate for assessment plus testing: $500

*ADHD/AUTISM Assessment Package: Includes the extended DA, testing, and 2 individual follow up sessions: $750. This requires a nonrefundable $500 deposit to hold the spot.

Therapy session rates For Licensed Providers:

Session, 30 minutes (90832): Billable rate: $150, DOS/Discounted rate: $95

Session, 45 minute (90834): Billable rate: $200, Discounted/DOS rate: $115 

Session, 55 minutes (90837): Billable rate: $250, DOS/Discounted rate: $135

Session, family (90846/90847): Billable rate: $275, DOS/Discounted rate: $135

Therapy Session rates for unlicensed providers

For those working towards licensure, self-pay rates are: $120 per hour session, $185 per DA.

For interns: Self-pay rates are at $60 per hour session

Add on codes

Interactive complexity (90785) add on code (In addition to above fees): communication struggles, more complex sessions, play therapy, interpreters, couples with complexity, such as EFCT, families with complexity, such as EFFT, Trauma with complexity/equipment, such as EMDR or ART sessions: Billable rate: $50, DOS/Discounted rate: $25

Services not billable to insurance that are patient responsibility:

Over 60 minutes: $50 per 15 minutes

Consultations, multiagency meetings, report writing: $50 per 15 minutes

Legal letter writing: $300 per document

Accelerated Resolution Therapy Session for 90 minutes: $200

REIKI Sessions: $70 for 60 minutes, $40 for 30 minutes. Please note payment is due within 24 hours of session and late cancels are not refunded.

EFT Tapping with Bryn Lowrie: $200 for 90 minutes, package of 5 sessions for $925, package of 12 sessions for $2040. Please note payment is due within 24 hours of session and late cancels are not refunded.

*Please note, *Court services are not billable to insurance. A $2000 deposit is required PER DAY. If court is cancelled/delayed for any reason from the date of subpoena to a week prior to subpoena date, we will refund $1,000 of your deposit. If court is canceled/delayed 24 hours or less, then we keep the entire deposit.

Less than 24 hour notice cancelation or no show of a therapy appointment: $50, Cancellation of an ADHD/Autism assessment: $100

Records request/retrieval: Minnesota Statute 144.292 allows providers to charge a retrieval fee for medical records sent to entities such as law offices, disability claims, and other organizations. While medical records requests will be fulfilled, there is an allowable 7 business days to fulfill the request. Please note fees are: retrieval Fee: $10 and per page: .75

INSURANCE INFORMATION AND AUTOHRIZATION I certify that the above information is true and correct to the best of my knowledge. I certify that I (or my dependent) have insurance coverage and assign directly to Jennifer Vaughn Therapy Services LLC DBA Acquire Mental Health, all insurance benefits, if any, otherwise, payable to me for services rendered. I understand and agree that I am ultimately responsible for payment; and that at this time services rendered may not be covered by my insurance. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the release of all information (notes, treatment plans, communication, etc) necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.