Clients must complete and sign this form prior to your first appointment. Office fees will be highlighted. These policies and procedures will establish the expectations you will receive from Cynthia Jackson LPC-S and also what is expected from you as the client. Collaboration between service providers and clients is most successful when all parties are aware of the objectives and standards of service

1. APPOINTMENTS: Please arrive to your appointment time.

   • Late arrival of 15 minutes or greater for any appointment may need to be rescheduled. If the appointment must be rescheduled, then the appointment is considered missed without cancellation. You will be charged $185.00 for the initial evaluation appointment and $100.00 for any other type of appointment.

   • Rescheduling appointments: You may cancel your appointment 24 hours prior to the appointment. If you need to reschedule call the office. You will be dismissed from the practice after (2) two missed appointments.

2. MISSED APPOINTMENT: If you have not cancelled your appointment in advance, you (not your insurance company), will be billed a fee for the missed appointment.

3. OTHER CLINICAL NEEDS: If you have a life threatening or emergent need please go to your nearest emergency room or call 911. If you have a clinical need please call the office and leave a message. Most calls left during business days (Monday-Friday) are returned by the next business day. Non-urgent calls left on Friday, Saturday or Sunday will be returned on Monday.

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  • Text Messages: Text messages are addressed as time permits therefore it is recommended you call the office for any urgent needs.

  • Email Response: Emails are addressed as time permits therefore it is recommended you call the office for any urgent needs. 

  • Non-secure email disclosure: Emails sent to (BNYPLLC@gmail.com/Brandnewyoucounseling@aol.com)or through the website portal may not be secure, therefore use at your own risk.

4. INSURANCE: A current insurance card must be presented at the first visit and when your insurance has changed. If not, you will be responsible for the self-pay rate of the appointment. 

• • If BRAND NEW YOU COUNSELING CENTER, PLLC is not contracted with your insurance carrier or your visit is a non-covered service, you are responsible for the charges.

  • I accept the following insurances.

    • United Healthcare

    • United Healthcare Community

    • Cigna

    • Aetna

    • UMR

    • Oscar

    • Magellan

    • Molina

    • Ambetter

    • Superior

    • Tricare

    • Beacon

 

5. PAYMENT:

• • We are currently using square and stripe to process any debit/credit card payments. We incur a fee for this transaction.

  • CHECKS are also accepted. There is a $50 fee for any checks returned for any reason. This fee is separate from the fee you will be charged by your bank for the returned check.

  • You may choose to have a debit/credit card on file. This credit card information will be stored in a secure vault within our electronic health record and considered on file. It will be used for any co-pays and remaining balance over 60 days old.

  • HSA cards are accepted and processed as a debit/credit card transaction through square.

I hereby authorize BRAND NEW YOU COUNSELING CENTER, PLLC to charge the debit/credit card on file for balances more than 60 days in arrears. This includes payments for missed appointments and fees that are not reimbursed or covered by my insurance.  

6. PAST DUE ACCOUNTS:

• • Any remaining balance after insurance has been filed is your responsibility.

  • You will receive two bills from BRAND NEW YOU COUNSELING CENTER PLLC. If you have not paid in full within 60 days your account will be turned over to a collection agency. If your account is sent to a collection agency, they will report your past due status to a Credit Reporting Agency and you will be responsible for their fees.  

I agree that BRAND NEW YOU COUNSELING CEENTGER , PLLC may contact me by telephone, electronic messages, mail or cell phone as provided by me or any person on my behalf or that are identified as mine at a later date. I understand that these communications may be from this medical provider and/or those providing services within the facilities of, or on behalf of, this medical provider including communications about the scheduling, treatment or payment for services rendered. These calls include but are not limited to using an automatic telephone dialing system, artificial or prerecorded voice or calls to a telephone number assigned to a paging service, cellular telephone service, specialized mobile radio service, or other radio common carrier service (“Authorized Communications”). I understand that my agreement to the terms of the Patient Consent and Assignment of Insurance Benefits is not a condition of willingness to provide treatment to me. I consent to any and all of the authorized communication methods even if I will incur a fee or a cost to receive such communications. I agree that the consent and authorizations I have provided herein may be revoked only in writing addressed to the relevant entity.

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1. COMPLETION OF FORMS: A fee is charged for the completion of forms including the following but not limited to: Disability, FMLA, and Leave of Absence, also Letters regarding flying and or airline tickets, therapeutic pet, . The client will always be notified of any charges upfront and payment may be requested prior to the release of the requested forms. 

Forms will be provided upon Patient registration.