Client Financial Agreement

This agreement describes the financial policies of Global Therapy, Inc. and applies to services provided by Donna M. Hunter, LCSW, and all clinicians associated with Global Therapy, Inc. The client or responsible party should read these policies before services begin. The Adult Consent for Services and Practice Agreement signed through the client portal incorporates these policies and documents the client's agreement to them.

1. Insurance, benefits, referrals, and authorizations

Global Therapy participates with some insurance plans and accepts contracted payment arrangements when required by an applicable provider agreement. As a courtesy, Global Therapy will submit claims to participating health plans and to other plans when the practice is able to do so. Claim submission, benefit verification, or an estimate of benefits is not a guarantee that an insurer or other payer will pay a claim.

The client or responsible party must provide accurate and current insurance information and should understand the plan's deductible, copayment, coinsurance, network requirements, coverage limits, exclusions, referral requirements, and authorization requirements. Global Therapy will reasonably assist with benefit verification or authorization when the payer assigns that responsibility to the provider.

When the client or responsible party is responsible for obtaining a referral or authorization, failure to obtain it may result in the service being noncovered. The client will be responsible only for amounts that may lawfully and contractually be billed to the client. Global Therapy will not transfer a charge to the client when doing so is prohibited by law, a payer contract, or an applicable billing rule.

The client authorizes Global Therapy and its billing service to submit claims, obtain information needed to administer benefits, receive direct payment or assignment of benefits when permitted, and use or disclose information necessary for treatment, payment, and health-care operations as permitted by law.

2. Client financial responsibility

The client or responsible party is responsible for properly documented charges assigned to the client under the applicable health plan, payer contract, self-pay arrangement, or law. These amounts may include:

• Copayments, deductibles, and coinsurance.
• Self-pay fees and services the client knowingly receives without using insurance.
• Noncovered services when the client has been informed that coverage may not be available.
• Services provided without a required referral or authorization when obtaining it was the client's responsibility.
• Other valid balances that may legally and contractually be billed to the client.

Insurance coverage is a contract between the client and the insurance carrier. Global Therapy cannot guarantee payment by an insurer. If a claim is denied or adjusted, Global Therapy will review the payer's explanation before billing the client. The client will not be held responsible for a charge that the payer contract or law requires Global Therapy to absorb.

3. Payment method and card-on-file authorization

A valid credit or debit card must ordinarily remain on file during treatment unless Global Therapy approves another written payment arrangement or an applicable law or payer rule requires otherwise. Payment information is maintained through the practice's secure payment system.

Through the signed Adult Consent for Services and Practice Agreement, the client or responsible party authorizes Global Therapy to charge the payment method on file for:

• Copayments, deductibles, coinsurance, and self-pay session fees.
• Estimated client responsibility when the estimate is based on available benefit information.
• Balances assigned to the client after claim processing or correction.
• Applicable late-cancellation or missed-appointment fees.
• Agreed nonclinical fees and other properly documented account balances.

Session fees or estimated client responsibility are ordinarily charged within 24 hours of the appointment. After a claim is processed, any remaining valid client responsibility may be charged to the payment method on file. Global Therapy will provide or make available a receipt or account record. If a charge is declined, the client will be notified and must provide a valid payment method or make an approved payment arrangement. Revoking card authorization does not eliminate a valid balance already incurred.

4. Appointments, cancellations, and missed appointments

Appointment time is reserved specifically for the client. New clients must provide at least 72 hours' notice to cancel or reschedule the initial appointment. Existing clients must provide at least 24 hours' notice to cancel or reschedule an appointment.

A late cancellation or missed appointment may result in a $100 fee when permitted by law and the applicable payer contract. This fee is not submitted to insurance and may be charged to the payment method on file. An exception may be made for an extraordinary circumstance at the treating clinician's discretion, but an exception is not guaranteed.

5. Standard fee schedule

The following are Global Therapy's current standard charges. A participating insurer's contracted allowed amount may differ from the standard charge.

• Initial diagnostic evaluation (90791): $300.
• Individual psychotherapy session (90837): $275.
• Family or couples psychotherapy session (90846 or 90847): $260.
• Extended or nonstandard service, when offered: $260 unless another fee is disclosed in advance.
• Standard self-pay psychotherapy session: $155.

The service code submitted must reflect the service actually provided and current coding and payer requirements. EAP services require authorization and are limited to the number and type of sessions approved. An EAP session may have no client copayment depending on the program. Clients will be informed of a material fee change before the new fee applies.

6. Additional professional and administrative fees

• Workers' compensation paperwork or other nonroutine form completion: $20 per page when permitted and disclosed in advance.
• Court-related preparation, consultation, record review, travel, deposition, or testimony: $500 per hour. Court appearance or testimony cannot be guaranteed.
• When court-related travel exceeds three hours, necessary transportation and lodging expenses are additional when agreed or legally recoverable.
• Unscheduled, nonemergency telephone consultation lasting more than 15 minutes: $10 for each 15-minute segment when agreed and not otherwise billed as a covered clinical service.
• Copies of health records: a reasonable, cost-based fee permitted by HIPAA and applicable state law. An advance estimate will be provided when required.

7. Returned payments

A $40 processing fee may be charged for a returned check to the extent permitted by law. A declined credit- or debit-card transaction does not, by itself, create a $40 returned-payment fee. The client or responsible party must promptly resolve the unpaid balance and provide a valid payment method.

8. Responsibility to update information

The client or responsible party must promptly notify Global Therapy of changes to insurance coverage, insurance benefits, name, address, telephone number, responsible-party information, or other information affecting billing or communication. Failure to report an insurance change may delay claim submission and may result in client responsibility when the charge may lawfully and contractually be billed to the client.

9. Statements, balances, and payment arrangements

Balances are due when billed unless a written payment plan or another approved arrangement applies. If a balance remains after services end, Global Therapy will issue or make available a billing statement, and payment is expected within 10 days unless another arrangement has been approved.

Clients experiencing financial hardship may ask whether a payment arrangement or financial-hardship review is available. Excessive or unresolved balances may affect future scheduling after appropriate notice and consideration of clinical needs, emergency circumstances, abandonment concerns, and continuity-of-care obligations.

10. Collection of unpaid accounts

If reasonable billing and collection efforts are unsuccessful and payment arrangements are not made, Global Therapy may refer a valid unpaid balance to Credit Recovery Corp. (CRC), another collection agency, or lawful legal process.

Global Therapy may disclose only the information reasonably necessary for payment or collection, consistent with HIPAA and other applicable law. This may include the client's or responsible party's name, contact information, date of birth, responsible-party or employment information when lawfully available and necessary, and information concerning the overdue balance. The client or responsible party is responsible only for collection costs actually incurred and legally chargeable to that person.

11. Good Faith Estimates for uninsured and self-pay clients

A client who is uninsured or who does not intend to submit a claim may have the right to receive a written Good Faith Estimate of expected charges under federal law. The estimate will be provided within the time required by law after services are scheduled or upon request. If the final bill is at least $400 more than the Good Faith Estimate, the client may be eligible to use the federal patient-provider dispute-resolution process. A Good Faith Estimate is not a guarantee of the exact course or cost of treatment because clinical needs may change.

12. Questions and acknowledgment

Questions about fees, insurance claims, payment arrangements, or account balances may be directed to Global Therapy at 479-268-4598.

By signing the Adult Consent for Services and Practice Agreement in the client portal, the client or responsible party confirms that they have read or had electronic access to this Client Financial Agreement, understand the financial policies, agree to the terms described above, authorize insurance billing and assignment of benefits as stated, and authorize charges to the payment method on file as described. This website page is the complete financial policy and does not require a separate signature.

Global Therapy, Inc. | 1002 McClain Road, Suite 108, Bentonville, AR 72712 | 479-268-4598

Original document

Download the original client financial agreement

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