Client Forms
Forms for new clients to Samaritan Counseling Center. If you have questions, please do not hesitate to contact us at
816-364-4300.
Client Information Form
Consent Form
Notice of Privacy
Privacy Practice Overview
Privacy Authorization
Policy Overview
HIPAA Authorization Form
If you do not have insurance, and are in need of financial assistance, please complete this form:
Financial Assistance Application
Proof of Income
If requesting assistance, please bring with you to your appointment: taxes or W2 from the previous year or your 2 most recent pay stubs OR an award letter from unemployment, disability, or retirement.
Please email forms with your insurance card front and back as well as a copy of your drivers license. [email protected]
NOTICE TO PATIENTS:
This practice serves all patients regardless of ability to pay. Discounts for essential services are offered based on family size and income.
For more information, ask at the front desk or visit our website.
Thank you.
AVISO PARA PACIENTES:
Esta práctica sirve a todos los pacientes, independientemente de la capacidad de pago. Descuentos para los servicios esenciales son ofrecidos dependiendo de tamaño de la familia y de los ingresos.
Usted puede solicitar un descuento en la recepción o visita nuestro sitio web.
Gracias
Common Questions
Below are quick overviews of the most requested patient policies of Samaritan Counseling Center. You may request to see the complete policy at any time.
SESSIONS: Regular individual or couple/family sessions are usually 45-60 minutes in length. Other time periods may be recommended by your therapist. Medication Management sessions are usually 20 minutes.
FEES: A current fee schedule for your provider is available on request.
CO-PAYS: Co-pays must be paid at time of service. Failure to make co-payments will result in cancellation of any future appointments.
NON-PAYMENT: Balances over 90 days old will be placed in internal collections. Balances over 120 will be turned over to a collection agency and you will be unable to schedule appointment until the balance is paid.
If you are having trouble paying your bill, please call to set up a payment plan.
PAYMENT PLANS: We are always willing to work with our clients to make reasonable payment plans. If you are having trouble paying your bill, please set up an appointment with the Office Manager to discuss a plan.
RETURNED CHECK FEES: A $25.00 charge will be assessed to your account for each returned check.
STATEMENTS: Client Statements are processed through our Electronic Health Record System. You will receive three (3) statements before being placed in collections. Payments may be mailed or brought to Samaritan Counseling Center or made through the Patient Portal. Please be sure and include the clients name on payments to assure proper credit.
INSURANCE ASSIGNMENT: Samaritan Counseling Center files insurance claims as a courtesy to our patients. In return we ask that you authorize your insurance company to make payments directly to Samaritan Counseling Center. If you do not wish to assign payment to Samaritan Counseling Center, we will provide you with a HIPPA compliant receipt for services. You will be required to pay for these services at the time of service.
INSURANCE COVERAGE: It is the responsibility of the client to determine if the services requested and provider are covered by your insurance plan. You are responsible for any co-payments, co-insurances, and non-covered services as determined by your insurance company.
If you lose coverage or change insurance plans, please notify Samaritan Counseling Center immediately.
FUNDING: All applicants are required to provide proof of income and fill out an application. Every application once approved is good for 6 months. All Social Welfare Board referrals are required to submit a new referral letter every 6 months.
SESSIONS: Regular individual or couple/family sessions are usually 45-60 minutes in length. Other time periods may be recommended by your therapist. Medication Management sessions are usually 20 minutes.
FEES: A current fee schedule for your provider is available on request.
CO-PAYS: Co-pays must be paid at time of service. Failure to make co-payments will result in cancellation of any future appointments.
NON-PAYMENT: Balances over 90 days old will be placed in internal collections. Balances over 120 will be turned over to a collection agency and you will be unable to schedule appointment until the balance is paid.
If you are having trouble paying your bill, please call to set up a payment plan.
PAYMENT PLANS: We are always willing to work with our clients to make reasonable payment plans. If you are having trouble paying your bill, please set up an appointment with the Office Manager to discuss a plan.
RETURNED CHECK FEES: A $25.00 charge will be assessed to your account for each returned check.
STATEMENTS: Client Statements are processed through our Electronic Health Record System. You will receive three (3) statements before being placed in collections. Payments may be mailed or brought to Samaritan Counseling Center or made through the Patient Portal. Please be sure and include the clients name on payments to assure proper credit.
INSURANCE ASSIGNMENT: Samaritan Counseling Center files insurance claims as a courtesy to our patients. In return we ask that you authorize your insurance company to make payments directly to Samaritan Counseling Center. If you do not wish to assign payment to Samaritan Counseling Center, we will provide you with a HIPPA compliant receipt for services. You will be required to pay for these services at the time of service.
INSURANCE COVERAGE: It is the responsibility of the client to determine if the services requested and provider are covered by your insurance plan. You are responsible for any co-payments, co-insurances, and non-covered services as determined by your insurance company.
If you lose coverage or change insurance plans, please notify Samaritan Counseling Center immediately.
FUNDING: All applicants are required to provide proof of income and fill out an application. Every application once approved is good for 6 months. All Social Welfare Board referrals are required to submit a new referral letter every 6 months.
