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This page contains links to the intake forms you receive as a new patient at The CENTER.

Client Information for 2017

CONFIDENTIALITY STATEMENT – CLIENT 2017

NOTICE OF PRIVACY 2017

Policy Overview 2017

Privacy auth 2017

 

** Needed only if patient does not currently have insurance:

2017 Funding Progam Application

Please also bring one of the following with you to your appointment: taxes from previous year (W2) OR 2 most recent pay stubs OR an award letter from unemployment, disability or retirement.

 

Below are quick overviews of the most requested patient policies of The 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.

NO SHOW CHARGE: If you do not call and cancel your appointment you will be charged: $50.00

After 3 consecutive No Shows you will no longer be able to schedule appointments at The CENTER.

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 The CENTER or made through the Patient Portal. Please be sure and include the clients name on payments to assure proper credit.

INSURANCE ASSIGNMENT:  The 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 The CENTER. If you do not wish to assign payment to The 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 The 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.