Anthem Blue Cross and Blue Shield New York (formerly Empire)

Aetna

Carelon Behavioral Health

Cigna

Blue Cross Blue Shield of Massachusetts

My rates are $150 per 60 minute session.

I have a $75 cancellation fee per session when cancelled within 24 hours

Under Section 2799-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.

· 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.

· 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.

· 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 healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

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

· There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate.

· Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith

Estimate, visit www.cms.gov/nosurprises or call 800-985-3059.

Providers check for voice mail messages during normal business hours. Messages left outside of normal hours of operation will be picked up the within 2 business days. If you are experiencing suicidal or homicidal thoughts, are in crisis, or need immediate help, please call 911 or go to the nearest emergency department.

I am usually not immediately available by telephone. You can leave a message on my confidential voicemail and I will return your call within 2 business days. I will make every attempt to inform you in advance of planned absences, and provide you with the name and phone number of the mental health professional covering my practice. If I need to cancel an appointment at the last-minute, I will reach out as soon as possible and reschedule.

There are several reasons why we may eventually end our professional relationship. You may decide you would prefer to work with a different provider. I may reach the conclusion you would be better served working with someone else. Regardless of the case, I will first discuss with you the reasons for discharging, and if you request, provide you with a list of other qualified providers. I will also extend the discharge process length if necessary based on your treatment needs, including continuing to provide emergency support for a time-limited period after you have been notified of the end of our treatment relationship.

Please note that ongoing failure to pay for treatment, attend sessions, or communicate with me in a respectful and timely manner can also result in discharge from my practice. In these instances, to ensure you have continued access to care, I will still make every reasonable effort to get in touch with you and provide referrals to a new provider before I consider our relationship ended.

No mobile information or personal details will be shared with third parties/affiliates

for marketing/promotional purposes.

All the above categories exclude text messaging originator opt-in data

and consent; this information will not be shared with any third parties.

Detailed practice policy provided to new clients at the time of scheduled intake appointment, or upon their request.

I may use SMS text messaging for certain types of communication with you, including billing, customer service, appointment reminders and other administrative requests.

Client full name: _______________

Client mobile #: _______________(Optional)

Providing me with your mobile phone number is optional. It will not affect my services to you. By entering your phone number, you agree to receive informational SMS messages (appointment reminders, account notifications, etc.) from Shannon Wagner, LCSW. Message frequency varies. Message and data rates may apply. For help, reply HELP or email me at shannonwagnerlcsw@gmail.com. You can opt out at any time by replying STOP. See Privacy Policy & Terms and Conditions below.

Messaging Terms & Conditions:

You agree to receive informational messages (appointment reminders, account notifications, etc.) from Shannon Wagner, LCSW. Message frequency varies. Message and data rates may apply. For help, reply HELP or email me at shannonwagnerlcsw@gmail.com. You can opt out at any time by replying STOP.

Mobile SMS Messaging Privacy Policy:

Information collected:
I may collect information, such as name, phone number, and email address.

Use of information collected:

I may use the information I collect to perform the services requested including billing, customer service, appointment reminders and other administrative requests.

Sharing of information collected:
I may share information I collect with payment processors, legal authorities, partners so that these service providers can perform their normal duties. I do not share, sell, rent, or trade any information provided with third parties for promotional purposes.

As a current or prospective customer, you understand that you can text me STOP at any time to opt out of receiving SMS text messages from us. You can text me HELP at any time to receive help. You understand that the messaging frequency may vary. Messaging & data rates may apply. Your mobile information will not be shared with any third parties/affiliates for marketing/promotional purposes. All policies are followed as per CTIA guidelines 5.2.1. At any time if you want your information to be removed, you can contact me via our email address or regular mail.

You can contact me for any privacy related queries via our email address or regular mail.

Our email address:
shannonwagnerlcsw@gmail.com

Client signature: _______________

Date: _______________