Office Hours: Our office hours vary according to patient needs. We do have evening appointments for your convenience. The office staff will help you schedule your appointments to coincide with your therapist’s schedule. You may leave a message on voicemail after hours.
Appointments: This office requires 24 hour notice of appointment cancellation. If you are unable to keep an appointment due to weather, illness or other reasons, please contact us immediately. We bill for missed appointments for which we are not notified.
Appointment Time: We will try to schedule appointments to meet your needs. At times though, due to emergency situations, you may be seen later than your scheduled appointment. You may call the office on the day of your appointment to check if your therapist is on schedule.
Medical Insurance Coverage: You are responsible for payment of services. You may have medical insurance which continues your financial benefits, but that matter is solely between you and your insurance company.
We are dedicated to providing you with the best possible care. If you have medical insurance, we are eager to help you receive your maximum allowable benefits. We will gladly answer any questions relating to your insurance. You must realize, however, that your insurance is a contract between you, your employer and the insurance company. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services that they will not cover. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered. All charges are assessed at 1.5% interest after 60 days. We require that your copayment be paid at the time of services rendered. If you do not know what your copayment may be, check with your insurance company. Full payment at the time of service is required if you do not want your insurance billed.
Many insurance companies authorize a limited number of visits per year for mental health services. It is your responsibility to keep track of the number of mental health visits per year including mental health visits outside this office.
Fee Schedule (subject to change): Therapist rates are $125.00 per hour (50-60 minutes).
Payment Policy: We accept cash, checks, Visa or MasterCard. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact our office staff as promptly as you can for assistance in the management of your account. If we do not hear from you within 90 days, your account will be turned over to collections.
Consent for Purposes of Treatment, Payment and Healthcare Operations: I consent to the use or disclosure of my protected health information (PHI) by the Counseling Center of Iowa City for the purpose of diagnosing or providing treatment to me, obtaining payment for my healthcare bills, or to conduct healthcare operations of the Counseling Center of Iowa City. I understand the diagnosis or treatment of me by my therapist may be conditioned upon my consent as evidence by my signature on this document.
I understand I have the right to request a restriction as to how my PHI is used or disclosed to carry out treatment, payment, or healthcare operations of the practice. The Counseling Center of Iowa City is not required to agree to the restrictions that I may request. However, if the Counseling Center of Iowa City agrees to a restriction that I request, the restriction is binding on the Counseling Center of Iowa City.
I have the right to revoke this consent in writing at any time except to the extent that my therapist or the Counseling Center of Iowa City has taken action in reliance of this consent.
My PHI means health information, including my demographic information, collected from me and created or received by my therapist, another healthcare provider, a health plan, my employer, or a healthcare clearinghouse. This PHI relates to my past, present, or future physical or mental health condition and identifies me, if there is a reasonable basis to believe the information may identify me.
I understand I have a right to review the Counseling Center of Iowa City Notice of Privacy Practices prior to signing this document. The Counseling Center of Iowa City Notice of Privacy Practices is located in the waiting room. Please refer to this document for a more complete description of the uses and disclosures that office/staff may use of your PHI. This Notice of Privacy Practices also describes my rights and the Counseling Center of Iowa City’s duties with respect to my PHI.
The Counseling Center of Iowa City reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a copy of the current Notice of Privacy Practices by requesting this in writing or in person.
Informed Consent: I have chosen to receive treatment through the Counseling Center of Iowa City. My choice has been voluntary and I understand that I may terminate therapy at any time.
I understand that psychotherapy is a cooperative effort between my counselor and me.
I understand that at times sensitive material may be discussed to resolve my problems.
I understand that I have a right to review all records kept about me.
I have read your office policy and agree to accept the responsibility of payment in full for services rendered.
Signature: _________________________________ Date: ______________