Patient Services Agreement

The patient certifies that the above information regarding insurance coverage is correct and also authorizes the disclosure of all necessary information, including the medical information necessary to decide any claim to the insurance company or payer. If HippoHealth is a provider participating in the patient`s initial insurance, HippoHealth will charge directly to the insurance company as a courtesy to the patient. This direct tally is called “assignment” of the right to pay the patient by the insurance company. This agreement constitutes such an assignment and authorizes Hippo Health to receive and retain the insurance company`s payment for the debt. If Hippo Health is not a provider participating in the patient`s initial insurance, Hippo Health is billed directly to the patient and the patient is responsible for obtaining a refund from the insurance agency. The fees for Hutchinson-Associate therapists vary slightly. Your therapist will confirm your scheduling costs at your first meeting or phone call. In addition to weekly appointments, you can assume that you will be charged for other professional services you need. Other services include writing reports, making phone calls longer than 15 minutes, consulting with other professionals with your permission, producing files or processing resumes, and spending time performing other services you can request. If you are involved in legal proceedings, you are expected to pay for your therapist`s professional time, including preparation and transportation costs, even if you are called as a witness by another party.

Due to the difficulty of legal participation, you can expect a higher hourly rate for legal work than for the usual consulting fees. If your account has not been paid for more than 60 days and payment terms have not been made, we have the option to secure the payment by legal means. This may involve shutting down a collection agency or executing actions for minor damages. This requires the disclosure of confidential information. In most cases of investigation, the name, social security number, date of birth, address, telephone number, financial history, type of services provided and amount owed are published. If such an action is necessary, its costs are included in the law. The law requires that we receive your signature recognizing that we have provided this information to you until the end of our first meeting. It is important that you understand the service agreement and HIPAA policies for your privacy policy. We can discuss all the issues you have. If you sign the consent form, it is also an agreement between us.

You can revoke this contract in writing at any time. This revocation will take effect on the date the revocation is submitted to us, unless there are obligations imposed on us by your health insurer to process your policy claims; or if you have not fulfilled your financial obligations. The patient agrees to obtain medical, diagnostic and other therapeutic services that may be provided by hippoa Health physicians and staff as part of the patient`s management during these and other meetings with the patient`s department, including, but not limited to diagnostic and therapeutic procedures and other services provided to the patient on instruction from the Hippo Health physician. Patients under the age of 17 who are not emancipated and their parents should be aware that the law can allow parents to review their child`s treatment records. Since private life in psychotherapy is often crucial to successful progress, especially among adolescents, our policy is generally to require parents to agree to give up their access to their child`s records. If they agree, we will provide them with general information on the status of the child`s treatment and participation in scheduled meetings during the processing process.

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