Psychiatric Intake Form (Page 6 of 11) in pdf

Hello and welcome to our center for health and wellbeing where licensed healthcare professional use the center to

see clients. The location is designed to meet the needs of the local community and provide professional services for

individuals, couples, family, adults of all ages, adolescents and children.

Counseling Services for Wellbeing is an independent service, retained by your healthcare professional to process

payment, submit insurance billings and perform a myriad of administrative tasks. Each provider that uses the services

of Counseling Services for Wellbeing is a separate and independent business and is responsible for being licensed

by the Washington State Department of Health to provide and supervise your care. You can search the individual

credentials of any Washington State psychiatric or mental healthcare professional at or by calling (800)

525-0127.

We are committed to providing you with the highest quality administrative services as well as a warm, clean and

professional office setting to receive care directly from the provider of your choice.

If we can do anything to make your experience more enjoyable, please feel free to ask.

Sincerely,

Issy Kleiman, Clinical Director

Counseling Services for Wellbeing

IMPORTANT INFORMATION AND TERMS OF AGREEMENT PLEASE READ CAREFULLY AND SIGN WHERE INDICATED

Fees for Services

Healthcare providers using the services and facilities of Counseling Services for Wellbeing provide their services to clients

privately and accept a range of insurance plans. Please make sure your provider is in net- work if you would like to use your

insurance, or you may be subject to paying a higher copay, coinsurance or deductible. Private pay rates are determined by

each provider and can vary greatly depending on their availability and licensure. Please check with your provider regarding

their rates and in- quire if they provide any rates for multiple visits.

If you see a non-prescribing therapist (i.e. social worker or mental health counselor) the copay or coinsurance is usually the

same for each visit. However, if you are seeing a psychiatric nurse practitioner, they function similar to a medical doctor.

Like visits with other medical specialists, visits with a psychiatric nurse practitioner are billed based on many factors

including, but not limited to time, complexity, amount of therapy etc. As a result, your copay/coinsurance and the length of

the appointment MAY BE DIFFERENT for each visit.

Financial Responsibility and Insurance Billing Practices

Payment in full is due at the time of each session including private pay amounts, copays, and deductibles. You will be billed

for any remaining balance. If your provider is in network with your insurance carrier, your financial responsibility for each

visit is determined by your insurance carrier’s allowed amount for the service provided.

Insurance

Counseling Services for Wellbeing currently accepts most forms of insurance and can submit out-of-network claims (for

therapy only) if your service provider is not covered by your plan and you have out-of- network benefits available. We will

make every effort to confirm that your selected provider is contracted with your insurance carrier. In some cases, you may

receive a recommendation to see an out- of-network provider. Please provide full insurance information and your

insurance card upon your initial visit to determine eligibility of benefits, and obtain authorization from your insurance

provider when necessary prior to your first visit. If you have a change in insurance, please let us know as soon as possible,

Psychiatric Intake Form Page 6