View/Print: New Client Information Form
This is a Fragrance Free Zone
Out of respect for the folks who come here who are fragrance-sensitive, we request that you wear no perfume, cologne, shampoo, or other highly scented toiletries.
If you, or anybody who comes with you, are sick with a viral/bacterial infection (i.e. colds, coughs, runny noses, body aches, vomiting, diarrhea, etc) please do not come. If you are a parent and are sick, you may bring your child/client, and we ask that you wait in the car. Many people who come here have weakened immune systems, so what may appear to you as inconsequential sniffles can mean pneumonia for another. I retain the right to refuse to treat on a day when I think the person is contagious. It is easy to schedule sessions to make up for those lost to illness.
You are asked to be as prompt for your appointment time as possible. If you are going to be late, be sure to call to make sure you can still be seen. If you need to change the appointment, please do so by email @ C3Beta@msn.com, subject line "appointment change." Session charge made for a "no show" on a scheduled visit, or lack of 24 hour cancellation.
Financial Policies
The fees for our services are based on the usual and customary rates for biofeedback in this area. The fee for the initial intake session is $250.00. This consists of a telephone for history and symptom rating and the first visit to the office for the continuous performance testing, called QIK. Office visits are $90.
(Incontinence biofeedback sessions are $100.00 each.)
We take checks, cash, credit/debit cards. Beginning February 1, 2013 there is a $3 "swipe fee" due to the increase of service fees charged by both the banks and the credit card processing companies.
Appointments cancelled or missed with less than twenty-four (24) hours notice will be charged the full fee. Missed or cancelled appointments cannot be billed to your insurance company, and you will be fully responsible for this charge. Exception: If you are ill and have called at any time before the appointment time to cancel your appointment, there will be no charge.
Telephone consultations, reports, and letters to other professionals or your insurance company may be provided as a courtesy at no fee if they are infrequent and require less than 20 minutes. Most services requiring more time, such as reports, letters, or conferences, will be billed at a rate of $80.00 per hour.
Insurance
For clients who are insured, payment is due in full at the time of service. At your request, we will provide you with a 'superbill' that you can submit to your insurance company for them to reimburse you directly. You are responsible for getting preauthorization for treatment from your insurance company, if needed. Be sure to find out if your insurance company requires chart notes to accompany the billing. When an insurance company, such as Premera, states that they will cover biofeedback with a pre-authorization of medical necessity, keep in mind that it is Premera who determines that. State insurance regulations do not permit me to waive or reduce your deductible nor your copay for any session that is billed to your insurance carrier.
Unless otherwise arranged, payment is due at the time of service. There is a $25 charge for all returned checks. We take all major credit cards, with the exception of American Express.
Accounts not paid according to the arrangements stated above are both a business and a therapy concern. If you are having financial difficulties, please let us know so that alternative treatment or payment plans can be discussed. If there are other ongoing problems in handling your account, we reserve the right to suspend any ongoing treatment until your balance is paid. If a client is not making regular payments on the account balance, we also reserve the right to initiate legal collection procedures as authorized by state and federal law. Clients will be notified in writing before an account is referred for collections. Under these circumstances, you will also be responsible for all expenses, including reasonable attorney fees, accrued interest, and other associated costs.