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    • Clients are responsible for knowing their insurance benefits and plan requirements, Therefore, if your insurance company does not pay (unless it was an error in billing or getting prior authorization) you are responsible for all charges incurred.
    • The fee for an assessment for an episode of care is $200. Ongoing therapy is $175 per session (50 minutes). Group therapy cost depends on the group and time commitment.
    • There is a $30 charge for non-emergency no-shows and/or cancellations made less than 24 hours in advance (unless there are rules that prohibit us from doing this.) These cannot be submitted to your insurance company. This must be paid prior to your next scheduled visit.
    • If you become involved in a legal proceeding that require your therapist's participation, you will be expected to pay for all professional time, including transportation costs, even if called to testify by another party (fee for preparation and attendance at any legal proceeding is $150 per hour).
    • I will pay my co-payment of each visit and/or the total amount due.
    • I will notify you immediately of any changes in insurance company. Without such notification, any refusal on the part of my insurance carrier to pay for services because of needed preauthorization will be my responsibility.
    • I consent to release of protected health information to my insurance company or EAP group for the processing of claims, care coordination, and treatment determination needed to respond to the inquiry. I understand Cook Counseling Services LLC will give only the minimal necessary information needed to respond to the inquiry.
    • If I am covered or believe I am covered by Medical Assistance (MA), I authorize this office to contact the county or counties as it relates to my MA number and coverage. I also, authorize release of protected health information to MA for billing and prior authorization.
    • If my account becomes past due (60) days and I have not arranged for or made regular payments, I understand Cook Counseling Services LLC may turn my account over to a collection agency and/or small claims court to obtain payment. My failure to make payments or arrange payments to settle my account to tacit authorization for Cook Counseling Services to release the minimal protected health information necessary to the collection agency and/or small claims court. We reserve the right to terminate services at that time.

    I hereby assign all medical benefits to include major medical benefits to which I am entitled, including Medicare, private insurance and other health plans to Cook Counseling Services LLC. This assignment will remain in effect until revoked by in writing. A photocopy of this assignment is to be considered as valid as an original. In signing this, I am consenting to: 1) terms of billing, 2) release of health information as needed for collection purposes, and 3) medical benefit assignment.