Download FEE Agreement - Oregon Mental Health Services

MHS Oregon Mental Health Services, LLC
FEE AGREEMENT
This agreement is made between ___________________________________________________________________
and Oregon Mental Health Services, LLC. This agreement will remain in effect for one year.
____________________________________ (Consumer) agrees to the following:
1. Pay $________Initial assessment; Pay$__________ per hour of psychotherapy time billed. Cash discount of
$_______. Billed rate is $________;
2. Deductible Y/N Pay: $________per session until deductible is met. Pay $__________per session for Coinsurance/Co-Pay.
3. Payment is to be made at the time of the session by cash or check to Oregon Mental Health Services, LLC for the
full amount of the session, unless other payment arrangements are made. Payment in full will not be required if
insurance coverage is in place and verification of benefits indicates psychotherapy is a covered benefit. Any copay for psychotherapy is due at time of session;
4. Pay $35 no show/late cancellation fee if a session is missed or cancelled without notifying the therapist 24 hours
in advance. This fee is to be paid before another appointment is scheduled with the therapist. Failure to attend
a scheduled appointment for the second time without 24 hours cancellation notice will result in charge of $35
no-show/ late cancellation fee and may also result in discharge from treatment. Consumers whose care is
covered by the Wisconsin Medicaid Program may not be assessed a fee for missed appointments.
Appointments that are cancelled late due to illness of the consumer or illness of a person cared for by the
consumer are not subject to the late cancellation policy. Cancellation of sessions due to weather conditions that
present risk of travel by the consumer to the clinic are also not subject to the late cancellation policy. Failure to
notify the therapist prior to the scheduled appointment time when appointments are cancelled due to illness or
weather conditions is subject to the $35 no show fee and/or discharge from treatment .
5. ___________ I have received a copy of OMHS, LLC Payment Policy.
Client Initials
Oregon Mental Health Services, LLC agrees to the following:
1. Provide a statement to the consumer of account activity when the consumer is personally responsible for any
payment. The statement will include current psychotherapy time billed, pending insurance payments and any
payments made on the account.
2. Submit required paperwork for approval of mental health treatment to the appropriate reviewing personnel;
3. Provide for 24 hour voicemail capability for consumers to communicate with clinic staff;
4. Other payment arrangements__________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________
Client or authorized signature
_________________________________________________________________
Psychotherapist signature
165 W Netherwood Dr. Suite A
Oregon, WI 53575
608-835-5050 608-835-5010 Fax
__________________________
Date
____________________________________
Date
02/16
110 W. Linden Drive
Jefferson, WI 53549
920-674-5050 920-674-5010 Fax