Financial Responsibility and Insurance Billing Practices

Payment in full is due at the time of each session including private pay amounts, copays, coinsurance and deductibles. You will be billed for any remaining balance.

I reserve the right to bill my standard fees for case coordination, clinical and legal write-ups, and phone consultations exceeding 15 minutes per week. My time is valuable and is best served providing high quality professional services to you while you are here in session. There is no charge for routine telephone calls to our administrative staff regarding scheduling, appointments, or billing.

Collections Efforts: If an unpaid balance remains after 60 days, your balance will be turned over to our third party collections partner, Transworld Systems, and you will receive a series of phone calls and letters to remind you of your balance due. This will not impact your credit, but is a reminder that there is a balance due that is patient responsibility. If you believe that there is an error in our billing, and you should not have a balance, please let us know as soon as possible so we can research the issue.

Unpaid balances without a payment plan initiated after 120 days will initiate a phone collections effort by Transworld Systems for recovery, and some identifying confidential information will be released in this process. This may negatively impact your credit. It is very important that you update your contact information with us to ensure you are aware of your financial responsibility and receive your statements.

Insurance: I am currently accepting insurance and can bill out-of-network (for therapy only) if I am not covered by your plan, and you have out-of-network benefits available. I will make every effort to match you with providers who are contracted with your insurance, but may ask that you see an out-of-network provider in special needs situations and on a case-by-case basis. Please provide full insurance information and your insurance card upon your initial visit to determine eligibility of benefits, and obtain authorization from your insurance provider when necessary prior to your first visit. If you have a change in insurance, please let us know as soon as possible, so we can ensure payment.

If your insurance plan requires pre-authorization for services, it is ultimately the responsibility of the client to obtain this authorization prior to being seen by your provider. If you fail to obtain authorization, any and all charges incurred and not reimbursed, will be your financial responsibility.

Since you cost-share with your insurance company, in collaboration with the Mindful Therapy Group staff, we will do our best to estimate your portion at the time that you check in. Despite our best efforts, it is possible that once we get the claim back (usually 3-6 weeks after it is submitted), your cost-share may be higher than originally anticipated. We will notify you about any balance due with a monthly statement. If we overestimated the cost-share, the credit will be applied towards your future visits unless you specify otherwise. At the start of the each new calendar year in January, with new insurance plans taking effect along with new deductibles to be met, we will be re-verifying benefits and collecting your full visit fee that will be applied to your deductible, at the time of service.

Dismissal/Termination of care

It is your right to terminate your relationship with me for any reason. I may terminate my relationship with you in a few specific cases including being rude to staff, missing your appointments, abusing medications prescribed to you, not following up on your therapeutic plan, etc.


Information discussed during the course of therapy is confidential. By law, information concerning your treatment may be released only with the consent (written or verbal) of the person treated (or the person's guardian if applicable). In the event where there is suspected child or elder abuse or an imminent danger of harm to one's self or others, the law requires the release of confidential information. In these instances I am required to make a report to the appropriate authorities. In addition, the courts may subpoena treatment records in certain circumstances. Any type of release of confidential information will be discussed with you.

We are compliant with the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to personal health care information (PHI). HIPAA requires that we provide you with a Notice of Privacy Practices. This Notice, which is attached to this agreement, explains HIPAA in detail and its application to your personal health care information. An electronic copy can be found on our website at

I may ask you to allow an intern or other licensed professional in training to sit in on your sessions or participate in your care. Any use of your information for teaching purposes will not be transferred outside of our practice, and your PHI will be protected in accordance with our Privacy Practices as described below. You may opt out of this at any time.

Age of Consent

In accordance with RCW 71.34.530: Any minor thirteen years or older may request and receive outpatient mental health treatment without the consent of the minor's parent. Parental authorization, or authorization from a person who may consent on behalf of the minor pursuant to RCW 7.70.065, is required for outpatient treatment of a minor under the age of thirteen.