• I am an in-network provider for several insurance companies and you can request that I bill those companies directly for services.  Services are billed for on a monthly basis, unless alternative arrangements are made between the therapist & financial guardian.  

• Payment can be made in the form of check, cash, or credit card. 

• Electronic payments are processed through IvyPay.  A valid credit, HSA, or FSA card must be kept on file through IvyPay. The card on file will be automatically billed for outstanding balance over $500.  An account is not required, and you may cancel the card on file at any time by sending an email to support@talktoivy.com.  

• If any fees for service are outstanding 90 days following the date of service, I reserve the right to stop services with an appropriate referral to another therapist.  

• Any legal documents (parenting plans, court orders, custody arrangements) will be used to determine the financial guardian of an account.  If it is not clearly outlined in these documents, I reserve the right to determine who will be responsible for the cost of services based upon what is clinically indicated.  

• The Personal Pay Application determines rates for services that are not subject to established contracts. Several services are available that are not paid for by insurance and are out-of-pocket expenses.  These may include: services via telephone, some CPT codes, care coordination & file review/clinical summary. 

• All clients have the right to a “Good Faith Estimate” as outlined in the No Surprises Act.  Estimates provided do not reflect possible reimbursement by a 3rd party payer (insurance company), as each client’s insurance coverage varies greatly. 

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OMB Control Number [0938-XXXX] 

Expiration Date [01/01/2050] 

 

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

 

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. 

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• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. 

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• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

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• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. 

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• Make sure to save a copy or picture of your Good Faith Estimate. 

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For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call [406-763-6884].