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. We are in network for most major insurance companies.

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), there may be times they reimburse you. If this is the case, you are expected to pay your bill.

Cash Accounts (Date of Service)/Opt Out

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. You may opt out of using your insurance benefits. If you chose to opt out, payments are made directly to the clinic and will not count towards deductibles, unless it’s permitted by your plan. If you are choosing to opt out, please direct any questions to: 218-820-7671. By signing this form, you are acknowledging that you are freely choosing to opt out and self-pay.

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 218-820-7671. 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

You are ultimately responsible for your account balance. If your 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, you will receive a letter. If you still have not paid your bill in 90 days, your 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.

By signing below, you are also acknowledging that you will be suspended from services if your bill becomes over $300 regardless of payment plan in order to not accrue a high balance. Balances beyond $300 put our therapists in a dual role, which is unethical (debt collecting and therapist.

Court fees

Please note, *Court services are not billable to insurance. A $2000 deposit is required PER DAY requested. 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. It is expensive for us to testify, it puts us at a liability risk, we do get an attorney involved, and we have to cancel clients in order to testify. Please note that any requests for court involvement may indicate the therapy relationship is complete as it puts us in a dual role. Please see informed consent on the therapeutic concerns of requesting a therapist to be involved with court. Legal letter writing is $300 per letter.

Records Requests

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: $0.75.

Late cancelled or no show appointments

Please be aware that your therapist reserves the right to charge a late cancel fee of $50. *does not apply to Medicaid clients.

Please note, fees increase yearly. The following rates will take effect 5/1/2026 (updated 3/31/2026). Insurance Billing codes are in italics.

Rates for Licensed Providers

Intake/Diagnostic Assessment (90791): Billable rate: $375, DOS/Discounted rate: $210

Extended DA or Comprehensive assessments (90791 TG) [Extended DA or Comprehensive Assessment: Integrative assessments, DC 0-5 assessments, and/or complicated assessments with collateral contact.]: $525, DOS/Discounted: $310

Session, 30 minutes (90832): Billable rate: $175, DOS/Discounted rate: $75

Session, 45 minute (90834): Billable rate: $225, Discounted/DOS rate: $120

Session, 55 minutes (90837): Billable rate: $275, DOS/Discounted rate: $140

Session, family (90846/90847): Billable rate: $300, DOS/Discounted rate: $140

Interactive complexity (90785) [Add-on code. Interactive Complexity: 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

Neurodivergent Affirmation Testing

Health Insurance ADHD/Autism Assessments (90791 or 90791 TG): Billable rate: $525

Interactive complexity (90785) [add on code - used per each session]: Billable rate: $50

ADHD/AUTISM Assessment Package - DOS/Discounted rate $750*

(Includes the extended DA, testing, and 2 individual follow up sessions)

*Requires Nonrefundable $500 deposit

Rates for Unlicensed Providers

Intake/Diagnostic Assessment (90791): Billable rate: $375, DOS/Discounted rate: $190

Session, 30 minutes (90832): Billable rate: $175, DOS/Discounted rate: $65

Session, 45 minute (90834): Billable rate: $225, Discounted/DOS rate: $105

Session, 55 minutes (90837): Billable rate: $275, DOS/Discounted rate: $125

Session, family (90846/90847): Billable rate: $300, DOS/Discounted rate: $125

Interactive complexity (90785) [Add-on code. Interactive Complexity: 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

Rates for Unlicensed Interns

Intake/Diagnostic Assessment (90791): Billable rate: $375, DOS/Discounted rate: $65

Session, 55 minutes (90837): Billable rate: $275, DOS/Discounted rate: $65

Session, family (90846/90847): Billable rate: $300, DOS/Discounted rate: $65

Services not billable to insurance that are patient responsibility:

Extended sessions lasting over 60 minutes: $35 per 15 minutes

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

Legal letter writing: $325 per document

Records request/retrieval: $10 + $0.75 per page

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.

Cancelation or No Show Fee (less than 24 hour notice)

Cancelation or No Show for therapy session $50

Cancelation or No Show for ADHD/Autism Assessment $100

Court Services $2000 deposit (per day)

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.

Please note payment is due within 24 hours of session and late cancels are not refunded.

Reiki with Färden Healing Arts - Jodi

30 minutes $40

60 minutes $70

EFT Tapping (Emotional Freedom Technique) with Bryn Lowrie

1 session for 90 minutes$200

5 sessions for 90 minutes $925

12 sessions for 90 minutes $2040