AGREEMENT BETWEEN US

WHAT CAN I EXPECT FROM MY INITIAL VISIT?

We will meet to talk about what brings you to therapy. You are free to ask whatever you like! Please don’t hesitate to ask questions, whatever they may be. I will answer them to the best of my ability. I will ask questions, too. The initial assessment may take 1 to 3 sessions. During this time, I may ask your permission to contact previous providers to obtain past treatment information. This will give me the necessary information to completely understand your concerns and my ability to assist you. This is also an essential time period for us to ensure that we’re a good fit.

HOW DO I PAY FOR SESSIONS?

Sessions are 45-55 minutes and cost $150. Payment (cash or check) is due at the time of your appointment. Sliding scale is available. Please make out checks to VLS Counseling, PLLC. 

I hold a contractual relationship with Blue Cross Blue Shield and Blue Care Network and will bill them directly. There is often a co-pay that will be your responsibility to pay. Periodically, I send out an invoice that lists all session dates and the co-pay charges. These co-pays will be due upon receipt of the invoice. Upon request, I can write a detailed receipt/statement with your diagnostic and procedural codes needed for submission to your insurance if I am not in your network. I will provide all the support and guidance that I can if you are submitting Out-of-Network claims.

 WHAT IF I NEED TO CONTACT YOU BETWEEN APPOINTMENTS?

Please feel free to leave a message on my confidential voicemail: (734) 436-1270. I make every effort to return phone calls within 36 hours. If you are in an emergency situation, call 911 or proceed to your nearest emergency room for immediate care. 

WHAT IF I NEED TO CANCEL OR RESCHEDULE?

I understand that things come up. If you have an emergency or there is a dangerous weather condition, we will re-schedule and you will not be charged. If you find that you need to cancel/change an appointment, I ask that you give me at least 24 hours notice. This is so that I can offer the time to another client who needs it. If there are multiple missed sessions without prior notice, we will discuss it and I will start charging the out of pocket rate for those sessions. Insurance will not cover cancelled appointments, so you will be billed for these appointments directly.

AGREED!

I understand that sessions with VLS Counseling PLLC/Vanessa Levine-Smith are covered by insurance plans with Blue Cross Blue Shield and Blue Care Network. I understand that all self-pay bills and co-pays are to be paid upon receipt of the invoice that I will receive periodically. If my sessions are not covered by insurance or only partially covered at any point, I understand that I will pay the balance for my session. I understand that it is my responsibility to submit any claim and complete any necessary follow-up if I am out-of-network. As well, I understand that if I have a pattern of cancelling my sessions within 24 hours or do not show up for appointments, I will be billed the entire amount of the session. I have received a copy of the Privacy Practices Form and I understand it. I consent to all the terms above.

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