Client Terms and Conditions
(outlined and agreed by each client intake form submitted)
We reserve the right to release your health care information based upon a decision by me for medical emergency situations and in general for continuity of care. We will release your health care information to third party payers in order to receive payment for our services. We will use your health care information as needed to maintain our internal operations. We will release your information to anyone else that you may elect in writing to receive it. We will release information related to any work related injury to your employer. For continuity and quality of care, we may also receive information regarding your medical prescriptions from your pharmacy.
We reserve the right to:
Contact you via email and phone.
Email you a reminder of your upcoming appointments.
Leave information on your voicemail.
I agree to receive appointment reminders by email.
I understand that the delivery of emails cannot be guaranteed and are provided as a courtesy. I further accept responsibility for all appointments that are made by directly with me or one of my representatives, regardless of any email communication.
If multiple family members will be receiving treatment in connection with my own therapy sessions with me, you will provide a unique email address for each person.
Authorization to release medical information and assignments of benefit
You understand and agree that you ultimately responsible for any unpaid balance for services provided by my practice.
You authorize the release of any mental health, medical or other information required by the insurance provider necessary to process your claims. I further understand and agree that if any claims submitted to my insurance provider are declined payment for any reason, that I will be responsible for payment to Mthera, and that Mthera, will not be responsible to follow-up with any declined claims.
I authorize payment of mental health benefits to Mthera, PC for all current and future services.
Credit Card Authorization
I authorize Mthera, PC to charge the credit/debit card payment details provided for client services outlined within. I understand that Mthera, PC does not accept healthcare spending cards such as FSA, HRA, or HSA, and agree that charges for services will be made in advance of the scheduled service when possible.
The credit/debit card payment details provided by me (including updated credit/debit card payment details provided written or verbally in the future) will be used to pay for all services, including any other Mthera, PC client profiles previously agreed and associated with the previous supplied credit/debit card payment details, insurance co-pays, deductibles, scheduled appointments, missed appointment fees, and services that are declined by my insurance provider for any reason without prior notice to me. I agree that In the event I dispute a charge made to any credit/debit card payment details that I have provided, I will incur a non-refundable service fee of $50 per dispute, plus any dispute charge incurred by Mthera, PC, regardless of the outcome of the dispute. I further agree that the service fee be charged to any credit/debit card payment details I have provided immediately upon filing such dispute.
I understand and agree a charge of $125 will be assessed for all appointments cancelled with less than 48 hours notice of the scheduled appointment date and time, or if I am more than 10 minutes late to the scheduled time of appointment. I further understand that notice of request can only be accepted via phone message to (336) 791-2311 (press option 1), or email to "firstname.lastname@example.org". Please note that we treat each client ethically and with fairness, therefore our Appointment Policy is without leniency and is firm.
I agree to pay for all provided, cancelled, missed services, or unpaid services by direct charge to the credit/debit card(s) provided and authorized on file. I further agree that if the credit/debit card(s) provided and authorized on file is/are declined for any services or missed services, when due, I will incur a non-refundable declined payment fee of $35 (per service charge), plus 1.5% interest monthly on any unpaid balance.
If using insurance, I understand that I am responsible and agree to pay the current private pay session rate if this information is incomplete, if my insurance provider is out-of-network, or services are declined by my insurance provider for any reason. I further understand and agree that all service charges will be charged to my credit/debit card without prior notice to me.
I understand and agree that the fees for all services provided by Mthera are charged the prior business day of each scheduled service when possible unless covered by insurance. I understand and agree that if my insurance provider does not pay for any service within 30 days, or payment is declined for any reason, I will be charged the unpaid amount of the service to the credit/debit card details provided and on file without prior notice to me.
I agree to pay Mthera $25 per 12 minute increment (or portion thereof) for administrative service time, and a flat rate of $50 per 12 minute increment (or portion thereof) for my service time, for copies of client records, correspondence, or any request I make which requires Mthera to contact my insurance provider on my behalf.
I agree that in the event Mthera deems it necessary to collect any amount due and payable from me, I will be responsible for all amounts incurred to collect such amounts, including all legal fees, court costs, and Mthera fees.
I agree that in the event that my therapist is required by court order to participate in any legal proceedings that involve the client or a family member, to pay the hourly rate equal to the private pay per session rate I currently charge (with a 12 hour/session total minimum), plus any legal or out of pocket expenses, and provide 5 business days notice (Monday - Friday / excluding Federal holidays) prior to such required or requested legal proceedings.