We try hard to make services affordable for families and will work closely with you to keep your account current. We offer interest-free payment plans for clients who place a credit card number on file at our office. However, we also retain a bill collection agency for outstanding accounts that become delinquent. Please read each of the following paragraphs to assure your understanding of our billing procedure and ask your intake therapist if you have any questions about these procedures. You will be asked to check a box after each statement.
For independently licensed staff our usual and customary hourly fee is $150 for intakes and $120 for ongoing psychotherapy of 45 minutes in length. Your insurance company may have contracted a different rate for your therapy. Your copay and deductible may range from 100% of the cost of the sessions to no cost at all depending your plan. You will want to talk to your insurance company before your first session to find out what they will and won't pay. In addition to regular therapy and medication appointments, we charge for other professional services by the quarter hour. These include report writing, telephone conversations, attendance live or by video at meetings with other professionals you have requested and authorized us to attend, preparation of records or treatment summaries, and time spent performing any other service you may request. We usually do not charge for email and texting (see media policy below) unless you require a heavier than average use of these services. If you become involved in any legal proceedings that require the participation of our staff, you will be expected to pay for our professional time even if the staff member is called to testify by another party.
FPS charges a flat fee of $50 for all missed appointments or late cancelations. A missed appointment is any appointment not canceled. A late cancel is any appointment not canceled with 24 hours prior notice. Fees for missed or late-canceled appointments due to legitimate emergencies will usually be waived. If you cancel more than a third of your appointments or reschedule more than half your appointments, even if they are not late-canceled or late rescheduled, FPS staff may discuss terminating your case. Medication management and psychotherapy require consistent attendance and we typically have a list of people wanting to get in. We can't help you if you're not here on a consistent basis. While such termination is extremely rare, we do include it in our informed consent for such cases.
Clients must pay all costs for services that are not paid by an insurance carrier. While we try to verify insurance benefits before your treatment begins, you are ultimately responsible for knowing what will and won't be paid for. Though we rarely file a collections action, we reserve the right to do so if your account becomes past due and you have not placed a credit or debit card on file to make regular payments. By signing this document, you are releasing Family Psychological Services, LLC to provide necessary information to its designated collection agency. If you move or relocate without making arrangements with Family Psychological Services, LLC for future billing, you may be subject to immediate collection action. If you write us a check and it is returned, a $30 fee will be added to your account.
I have read the above statement about fees, collection, and billing, I understand them and I agree.
I need to discuss the above statement with a therapist at intake before I agree.
If you are over the age of 18 and have a parent or other individual guaranteeing your bill we must have the guarantors billing information, he or she must agree to a payment arrangement, or you must present a credit card in your name with an authorization to bill the card. If you request the bill be sent to your guarantor, you are agreeing that your billing information will be shared with him or her. Be aware that if the guarantor does not pay the bill, you will be ultimately responsible for its payment and subject to collections. Please provide the contact information for your guarantor if he or she is not the insurance policyholder noted above.
If you are a divorced parent presenting your child for treatment, by signing this document you are agreeing that you alone will be responsible for the bill, regardless of any court orders that may be in place. We will supply receipts for all services you purchase at this office so you can turn those in to the child’s other parent for full or partial payment, but you are ultimately responsible for any payments incurred, unless you obtain a guarantor statement from the child’s other parent. By checking this box you are agreeing to this stipulation. If your ex-spouse contacts this office and puts a credit card on file to split charges, we will honor that card for half the charges after insurance. However, you remain responsible for the bill if the non-presenting parent does not honor that agreement.
I am an adult client and thus not affected by this statement.
I am not a divorced parent and thus not affected by this statement.
I am a divorced parent presenting a child for therapy. I have read the above statement and I agree to pay all costs associated with my child's treatment.
You are ultimately responsible for your charges whether you pay cash or whether you are using insurance. Insurance clients nearly always incur copays, coinsurance, and deductible. Because insurance policies now vary so greatly and initial benefit disclosures from insurance companies do not guarantee payment, we require all clients to place a credit or debit card on file at our office to cover costs at time of service or within the scope of a payment plan agreed upon between you and FPS. FPS is authorized to charge Health Savings and Flex Benefits cards for services rendered in the covered year. The card number you provide will be transmitted through our HIPAA compliant email system (FPSSecure.com secured by LuxSci.com) and will be stored in a HIPAA compliant billing program (TherapyNotes LLC) both of which are password protected and can only be accessed from one of our computers. By signing this document, you are authorizing us to bill your credit card for all services not otherwise covered or, with prior approval, you may set up a flat-rate monthly payment plan which charges your card either on the 15th or the 30th of the month for an amount stated below.
I have read the above statement about placing my credit card on and I authorize Family Psychological Services charge services not covered by insurance (FPS does not accept into service anyone who does not have a viable form of payment on file).
I certify that I am currently on KanCare and will not owe a copay or other insurance charge.
This authorization will remain in force and effect until my account is closed or until Family Psychological Services, LLC Inc. has received written notification from me of its termination, in such time and such manner as to afford Family Psychological Services, LLC Inc. a reasonable opportunity to act on that request. I understand that if I cancel this agreement without making another payment arrangement my account will be considered delinquent and may be referred for collection action.
Electronically sign in the square below using your finger (touch screen) or a mouse or trackpad before you submit it. If you've never done this before, it's a bit of an awkward process and your signature won't look great, but it is a valid legal signature. You only get one chance, so do your best. This is NOT the signature for the entire document. Just the credit card authorization.
Clients who request them can receive a statement of billing for tax or reimbursement purposes. We can give you a paper statement in the office at any time. If you want to receive a statement and don't want to come by the office, we prefer to email using our HIPAA compliant email system (FPSSecure.com) which we have found to be more reliable since many of our clients move during college or in career transition but leave their emails the same. You will need to set up a password when you receive the email to access that information. We will also send statements by US Postal if requested to do so. Please accept at least one of the following:
Send my statements by secure email to this address:
Send my statements by US Postal to the address below (if you are a student, please us a permanent address:
Clients, who qualify by diagnosis and wish to do so, may choose to have their treatment costs reimbursed by a medical insurance carrier. By contract, we must bill your insurance company directly. By completing this form you authorize us to provide to your carrier whatever information is required to assure reimbursement for services we may render. Typically, this will include diagnosis, but some insurance companies like Blue Cross and Blue Shield of Kansas ask for more extensive information like treatment plans, goals and objectives. In fact, we have found it best to presume that when you elect to use insurance, your entire record is open to review. Insurance companies are bound by Federal laws guiding confidentiality, but Family Psychological Services, LLC cannot be responsible for any information once it is released to your insurance company or any use to which that company might submit it. To learn more about your insurance company’s policies on privacy and billing, contact them directly. Some clients prefer to avoid the exposure of private information and choose to pay cash instead of using insurance benefits, particularly when they have a high deductible plan. Please talk with the office manager if you prefer this option. We do not offer payment plans for clients who opt out of insurance.
Send Your Insurance Card. If you want us to bill your insurance we strongly encourage you to send a picture of your insurance card to firstname.lastname@example.org so we can review it before your appointment. This email is HIPAA-compliant and encrypted so your health information is secure. If you do not bring the information by the time of your first appointment, you will be considered a self-paying (cash) client until the card can be presented and we will bill you full fee for the session.
Medicare and KanCare (Medicaid). We do not accept any form of Medicare as primary or secondary insurance. Several of our providers accept KanCare (Medicaid) for children and adolescents within their scope of practice. At this time we do not see Medicare or Medicaid clients for medication management but our staff will work with other prescribers on your case as necessary.
Relationship and Sex Therapy. Treatment which is primarily intended to improve sexual functioning or relationships is not deemed to be "medically necessary" by insurance companies and thus those services are not covered. The exception to this rule is when these forms of treatment are used to treat other diagnosable conditions, like ADHD, anxiety, depression, etc. In these cases, insurance companies understand that involving family members, partners, and friends may improve outcomes for the identified individual client. Family Psychological Services strongly prefers to work this way. This is not, however, martial or relationship therapy, but what we refer to as a "conjoint therapy process" intended to treat one of the family members for conditions that may also have relational and sexual components. In most cases, partner participation can provide valuable treatment options, but the chart must be open on the identified and diagnosed client, the partner considered a "collateral" in that process, and the conjoint therapy must address the individual client's treatment goals.
Be aware that these limitations are not policies of Family Psychological Services, but requirements of insurance company contracts. Providers who bill for a marital-only or sex therapy (as opposed to conjoint services for an identified and properly diagnosed mental health condition) are doing so in violation of their insurance contract. Please feel free to discuss with our office the details if your case as far as insurance is concerned. Sometimes we can determine if your situation would or would not be billable through insurance.
Court Ordered Treatment. Insurance may or may not reimburse for any court-ordered treatments. Contact your insurance company to find out if this is covered on your policy and please provide us with a written statement to that effect before your intake session. This is also true of divorce or coparenting therapy that is not initiated in response to a specific mental health concern. Many times children and adults are having significant mental health problems adjusting to the divorce. Those situations are typically reimbursable by insurance because we can demonstrate "medical necessity" in terms of behavior, thought, and emotion related to the divorce. However, coparenting therapy, supervised therapy with parent and child to reintegrate their relationship, and any forensic service related to divorce is NEVER reimbursable. Under no circumstances will insurance or KanCare reimburse for court-ordered therapy if you do not also meet medical necessity requirements. You and your therapist will consider whether you meet those criteria in your first session.
I have read and understand the above insurance disclosure and have chosen the following (check just one box)
I am providing my information for FPS to bill my insurance company or KanCare.
I am DECLINING to provide insurance or KanCare information. I will pay cash in full at time of service or will provide a credit card on file.
I understand that my services fall into a category that will not be paid for by insurance and I will instead pay for them in full at time of service.
Please tell us about the family that raised the client. For minors, complete information about current family.