Good Faith Estimate:

Under Section 2799B-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 health care 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.

• 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

Notice of Privacy Practices:

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Four Peaks Counseling Services, PLC (the “Practice”) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and your rights regarding PHI that we collect and maintain.


YOUR RIGHTS
Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.

To inspect and copy PHI.
• You can ask for an electronic or paper copy of PHI. The Practice may charge you a reasonable fee.
• The Practice may deny your request if it believes the disclosure will endanger your life or another person's life. You may have a right to have this decision reviewed.

To amend PHI.
• You can ask to correct PHI you believe is incorrect or incomplete. The Practice may require you to make your request in writing and provide a reason for the request.
• The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement.

To request confidential communications.
• You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.

To limit what is used or shared.
• You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask the Practice not to share PHI with your health insurer.
• You can ask for the Practice not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.

To obtain a list of those with whom your PHI has been shared.
• You can ask for a list, called an accounting, of the times your health information has been shared. You can receive one accounting every 12 months at no charge, but you may be charged a reasonable fee if you ask for one more frequently.

To receive a copy of this Notice.
• You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.

To choose someone to act for you.
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.

To file a complaint if you feel your rights are violated.
• You can file a complaint by contacting the Practice using the following information:
Four Peaks Counseling Services, PLC
10245 E. Via Linda Suite 102 Scottsdale, AZ 85258
Lauren Robinson, MA, LPC
480-840-7467
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• The Practice will not retaliate against you for filing a complaint.

To opt out of receiving fundraising communications.
• The Practice may contact you for fundraising efforts, but you can ask not to be contacted again.


OUR USES AND DISCLOSURES
1. Routine Uses and Disclosures of PHI
The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The Practice typically uses or shares your health information in the following ways:

To treat you.
• The Practice can use and share PHI with other professionals who are treating you.
• Example: Your primary care doctor asks about your mental health treatment.

To run the health care operations.
• The Practice can use and share PHI to run the business, improve your care, and contact you.
• Example: The Practice uses PHI to send you appointment reminders if you choose.

To bill for your services.
• The Practice can use and share PHI to bill and get payment from health plans or other entities.
• Example: The Practice gives PHI to your health insurance plan so it will pay for your services.

2. Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to Object
The Practice may use or disclose PHI without your authorization or an opportunity for you to object, including:

To help with public health and safety issues
• Public health: To prevent the spread of disease, assist in product recalls, and report adverse reactions to medication.
• Required by the Secretary of Health and Human Services: We may be required to disclose your PHI to the Secretary of Health and Human Services to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information.
• Health oversight: For audits, investigations, and inspections by government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.
• Serious threat to health or safety: To prevent a serious and imminent threat.
• Abuse or Neglect: To report abuse, neglect, or domestic violence.

To comply with law, law enforcement, or other government requests
• Required by law: If required by federal, state or local law.
• Judicial and administrative proceedings: To respond to a court order, subpoena, or discovery request.
• Law enforcement: For law locate and identify you or disclose information about a victim of a crime.
• Specialized Government Functions: For military or national security concerns, including intelligence, protective services for heads of state, or your security clearance.
• National security and intelligence activities: For intelligence, counterintelligence, protection of the President, other authorized persons or foreign heads of state, for purpose of determining your own security clearance and other national security activities authorized by law.
• Workers' Compensation: To comply with workers' compensation laws or support claims.

To comply with other requests
• Coroners and Funeral Directors: To perform their legally authorized duties.
• Organ Donation: For organ donation or transplantation.
• Research: For research that has been approved by an institutional review board.
• Inmates: The Practice created or received your PHI in the course of providing care.
• Business Associates: To organizations that perform functions, activities or services on our behalf.

3. Uses and Disclosures of PHI That May Be Made With Your Authorization or Opportunity to Object
Unless you object, the Practice may disclose PHI:

To your family, friends, or others if PHI directly relates to that person's involvement in your care.

If it is in your best interest because you are unable to state your preference.

4. Uses and Disclosures of PHI Based Upon Your Written Authorization
The Practice must obtain your written authorization to use and/or disclose PHI for the following purposes:

Marketing, sale of PHI, and psychotherapy notes.

You may revoke your authorization, at any time, by contacting the Practice in writing, using the information above. The Practice will not use or share PHI other than as described in Notice unless you give your permission in writing.


OUR RESPONSIBILITIES
• The Practice is required by law to maintain the privacy and security of PHI.
• The Practice is required to abide by the terms of this Notice currently in effect. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law.
• The Practice reserves the right to amend Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice, using the information above.
• The Practice will inform you if PHI is compromised in a breach.

This Notice is effective on 11/16/2021.

Consent for Services:

Welcome to Four Peaks Counseling Services (FPCS). This form is called a Consent for Services (the "Consent"). In this document, you will find important information about FPCS’s professional services and business policies. It will also be providing you with information about your rights under HIPAA, and obtaining a signature that indicates that you have received and understand these rights. When you sign this document, it will represent an agreement between us. Please take your time to read this information carefully and in its entirety, and let your therapist know if you have any questions. This form will be posted on the website www.fourpeakscounseling.com for your review, and your signed copy will be saved in your secure client portal.

THE THERAPY PROCESS
Therapy is a collaborative process where you and your Provider will work together on equal footing to achieve goals that you define. This means that you will follow a defined process supported by scientific evidence, where you and your Provider have specific rights and responsibilities. Therapy generally shows positive outcomes for individuals who follow the process. Better outcomes are often associated with a good relationship between a client and their Provider. To foster the best possible relationship, it is important you understand as much about the process before deciding to commit.

Therapy begins with the intake process. First, you will review your Provider's policies and procedures, talk about fees, identify emergency contacts, and decide if you want health insurance to pay your fees depending on your plan's benefits. Second, you will discuss what to expect during therapy, including the type of therapy, the length of treatment, and the risks and benefits. If your Provider is practicing under the supervision of another professional, your Provider will tell you about their supervision and the name of the supervising professional. Third, you will form a treatment plan, including the type of therapy, how often you will attend therapy, your short- and long-term goals, and the steps you will take to achieve them. Over time, you and your Provider may edit your treatment plan to be sure it describes your goals and steps you need to take. After intake, you will attend regular therapy sessions at your Provider's office or through video, called telehealth. Participation in therapy is voluntary - you can stop at any time. At some point, you will achieve your goals. At this time, you will review your progress, identify supports that will help you maintain your progress, and discuss how to return to therapy if you need it in the future.

Therapy often involves a significant commitment of time, money and energy, so you should be thoughtful about the process and the therapist that you select to work with. If you have any questions about your therapist’s procedures or recommendations, it is important to bring them up as they arise, so that you may discuss them. If for any reason, you or your therapist, does not feel that you are well suited to effectively work on your therapeutic goals, the therapist will assist you with a referral to another mental health professional.

Therapy sessions are typically 45-50 minutes, unless a 90 minute session is scheduled In advance, on a weekly basis. However, the frequency of sessions may vary depending on your specific clinical needs and goals. Please be aware that session times fill up fairly quickly, so it can be difficult to schedule one week to the next. The therapist will always try to provide a set weekly time slot for you when available.

IN-PERSON VISITS & SARS-CoV-2 ("COVID-19")
When guidance from public health authorities allows and your Provider offers, you can meet in-person. If you attend therapy in-person, you understand:
• You can only attend if you are symptom-free (For symptoms, see: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html);
• If you are experiencing symptoms, you can switch to a telehealth appointment or cancel. If you need to cancel due to illness, you will not be charged a late cancellation fee.
• You must follow all safety protocols established by the practice, including:
• Following the check-in procedure;
• Washing or sanitizing your hands upon entering the practice;
• Adhering to appropriate social distancing measures;
• Wearing a mask, if required;
• Telling your Provider if you have a high risk of exposure to COVID-19, such as through school, work, or commuting; and
• Telling your Provider if you or someone in your home tests positive for COVID-19.
• Your Provider may be mandated to report to public health authorities if you have been in the office and have tested positive for infection. If so, your Provider may make the report without your permission, but will only share necessary information. Your Provider will never share details about your visit. Because the COVID-19 pandemic is ongoing, your ability to meet in person could change with minimal or no notice. By signing this Consent, you understand that you could be exposed to COVID-19 if you attend in-person sessions. If a member of the practice tests positive for COVID-19, you will be notified. If you have any questions, or if you want a copy of this policy, please ask.

TELEHEALTH SERVICES
To use telehealth, you need an internet connection and a device with a camera for video. Your Provider can explain how to log in and use any features on the telehealth platform. If telehealth is not a good fit for you, your Provider will recommend a different option. There are some risks and benefits to using telehealth:
• Risks
• Privacy and Confidentiality. You may be asked to share personal information with the telehealth platform to create an account, such as your name, date of birth, location, and contact information. Your Provider carefully vets any telehealth platform to ensure your information is secured to the appropriate standards. Because telepsychology sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. On my end I will take reasonable steps to ensure your privacy. But it is important for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation.
• Technology. There are many ways that technology issues might impact telepsychology. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies. If you have issues during a session, your Provider will follow the backup plan. If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call me back; instead, call 911 or go to your nearest emergency room. Call me back after you have called or obtained emergency services. If the session is interrupted and you are not having an emergency, disconnect from the session and I will wait two (2) minutes and then re-contact you via the telepsychology platform on which we agreed to conduct therapy. If you do not receive a call back within two (2) minutes, then call me on the phone number I provided you (480-840-7467). If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time.
• Crisis Management. It may be difficult for your Provider to provide immediate support during an emergency or crisis. You and your Provider will develop a plan for emergencies or crises, such as choosing a local emergency contact, creating a communication plan, and making a list of local support, emergency, and crisis services. Usually, I will not engage in telepsychology with clients who are currently in a crisis situation requiring high levels of support and intervention. I will ask that you sign this consent form as authorization allowing me to contact your emergency contact person as needed during such a crisis or emergency.
- Efficacy. Most research shows that telepsychology is about as effective as in-person psychotherapy. However, some therapists believe that something is lost by not being in the same room. For example, there is debate about a therapist’s ability to fully understand non-verbal information when working remotely. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist’s inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally to the therapist.
- Confidentiality: I have a legal and ethical responsibility to make my best efforts to protect all communications that are a part of our telepsychology. However, the nature of electronic communications technologies is such that I cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. I will try to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for telepsychology sessions and having passwords to protect the device you use for telepsychology). The extent of confidentiality and the exceptions to confidentiality that I outlined in my Informed Consent below still apply in telepsychology. Please let me know if you have any questions about exceptions to confidentiality.
• Benefits
• Flexibility. You can attend therapy wherever is convenient for you.
• Ease of Access. You can attend telehealth sessions without worrying about traveling, meaning you can schedule less time per session and can attend therapy during inclement weather or illness.
• Recommendations
• Make sure that other people cannot hear your conversation or see your screen during sessions.
• Do not use video or audio to record your session unless you ask your Provider for their permission in advance.
• Make sure to let your Provider know if you are not in your usual location before starting any telehealth session.
Fees Related to Telehealth:
The same fee rates will apply for telepsychology as apply for in-person psychotherapy. However, insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If your insurance does not cover electronic psychotherapy sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to our engaging in telepsychology sessions in order to determine whether these sessions will be covered.

By signing this consent, I am also opting in to receive emailed invoices for payment of services. If I do not wish to receive email invoices, I will notify the therapist and request that paper invoices be emailed to me directly to be paid to therapist via check upon receipt of paper invoice.

TELEHEALTH SESSIONS:
1. I understand that my health care provider is offering me to engage in a telehealth session.
2. My health care provider explained to me how the video conferencing technology that will be used to perform such a session will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
3. I understand that a telehealth session has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
CONSENT TO USE THE TELEHEALTH BY SECUREVIDEO SERVICE
Telehealth by Securevideo is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:
1. Telehealth by Securevideo is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
2. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither Securevideo nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
3. The Telehealth by Securevideo Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
4. I do not assume that my provider has access to any or all of the technical information in the Telehealth by Securevideo Service – or that such information is current, accurate or up to date. I will not rely on my health care provider to have any of this information in the Telehealth by Securevideo Service.
5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

In Case of an Emergency
If you have a mental health emergency, I encourage you not to wait for communication back from me, but to do one or more of the following: - Call Lifeline at (800) 273-8255 (National Crisis Line) - Call 911 - Go to the emergency room of your choice

Emergency procedures specific to Telehealth services
There are additional procedures that we need to have in place specific to Telehealth services. These are for your safety in case of an emergency and are as follows: You understand that if you are having suicidal or homicidal thoughts, experiencing psychotic symptoms, or in a crisis that we cannot solve remotely, I may determine that you need a higher level of care and Telehealth services are not appropriate. I require two Emergency Contact People (ECP) who I may contact on your behalf in a life-threatening emergency only. Either you or I will verify that your ECP is willing and able to go to your location in the event of an emergency. Additionally, if either you, your ECP, or I determine necessary, the ECP agrees take you to a hospital. Your signature at the end of this document indicates that you understand I will only contact this individual in the extreme circumstances stated above. You agree to inform me of the address where you are at the beginning of every session. You agree to inform me of the nearest mental health hospital to your primary location that you prefer to go to in the event of a mental health emergency. You agree to inform me of the nearest police department to your primary location that you prefer to go to in the event of an emergency.


CONFIDENTIALITY
Your Provider will not disclose your personal information without your permission unless required by law. If your Provider must disclose your personal information without your permission, your Provider will only disclose the minimum necessary to satisfy the obligation. However, there are a few exceptions.
• Your Provider may speak to other healthcare providers involved in your care.
• Your Provider may speak to emergency personnel.
• If you report that another healthcare provider is engaging in inappropriate behavior, your Provider may be required to report this information to the appropriate licensing board. Your Provider will discuss making this report with you first, and will only share the minimum information needed while making a report. If your Provider must share your personal information without getting your permission first, they will only share the minimum information needed. There are a few times that your Provider may not keep your personal information confidential.
• If your Provider believes there is a specific, credible threat of harm to someone else, they may be required by law or may make their own decision about whether to warn the other person and notify law enforcement. The term specific, credible threat is defined by state law. These actions may include notifying the potential victim, calling the police, and/or seeking
hospitalization for the client. Your Provider can explain more if you have questions.
• If your Provider has reason to believe a minor or elderly individual is a victim of abuse or neglect, they are required by law to contact the appropriate authorities.
• If your Provider believes that you are at imminent risk of harming yourself, they may contact law enforcement or other crisis services. However, before contacting emergency or crisis services, your Provider will work with you to discuss other options to keep you safe.

On occasion, it may be helpful for your therapist to consult other professionals about a case. Case consultation is a normal and professional aspect of therapy for your counselor. During these consultations, every effort is made to avoid revealing any identifying information about the client. The consultant is also legally and ethically bound to keep the information shared with him/her confidential. If you do not object, the therapist will not tell you about the consultations unless it is felt to be important in your work together. Please let your therapist know if you have any questions or concerns about any of the important information shared regarding confidentiality.

RECORD KEEPING
Your Provider is required to keep records about your treatment. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care. Your records are maintained in an electronic health record provided by TherapyNotes. TherapyNotes has several safety features to protect your personal information, including advanced encryption techniques to make your personal information difficult to decode, firewalls to prevent unauthorized access, and a team of professionals monitoring the system for suspicious activity. TherapyNotes keeps records of all log-ins and actions within the system. By law, Four Peaks Counseling is required to keeptreatment records for 7 years after therapy has concluded. Due to the professional nature of the
documents, it is best to review the documents in the presence of your therapist. This allows for you to ask any questions or address any concerns, to avoid any misinterpretation or misunderstanding of the professional wording in the documents.

COMMUNICATION

Simply due to the nature of this profession, your therapist is often not immediately available by phone. During emergencies, do not leave a message. Please call 911 or go to your nearest emergency room. Otherwise, a message can be left on their voicemail at any time of the day or night, which will be monitored frequently during the weekdays, although less frequent on the weekends and holidays. The therapist will make every effort to return your call by the next business day. Please make sure to leave your name, contact number, times you will be available to be reached, and any special instructions with respect to leaving messages with family members or coworkers.
• Texting/Email
• Texting and email are not secure methods of communication and should not be used to communicate personal information. You may choose to receive appointment reminders via text message or email. You should carefully consider who may have access to your text messages or emails before choosing to communicate via either method.
• Secure Communication
• Secure communications are the best way to communicate personal information, though no method is entirely without risk. Your Provider will discuss options available to you. If you decide to be contacted via non-secure methods, your Provider will document this in your record.
• Social Media/Review Websites
• If you try to communicate with your Provider via these methods, they will not respond. This includes any form of friend or contact request, @mention, direct message, wall post, and so on. This is to protect your confidentiality and ensure appropriate boundaries in therapy.
• Your provider may publish content on various social media websites or blogs. There is no expectation that you will follow, comment on, or otherwise engage with any content. If you do choose to follow your Provider on any platform, they will not follow you back.
• If you see your Provider on any form of review website, it is not a solicitation for a review. Many such sites scrape business listings and may automatically include your Provider. If you choose to leave a review of your Provider on any website, they will not respond. While you are always free to express yourself in the manner you choose, please be aware of the potential impact on your confidentiality prior to leaving a review. It is often impossible to remove reviews later, and some sites aggregate reviews from several platforms leading to your review appearing other places without your knowledge.
- Intra-Session Therapeutic Email Communication
The therapeutic process is not complete without a little work outside the office sessions. From time to time, you may wish to communicate with your counselor between sessions to answer a quick question, vent a situation, or just check in. Now, as an added service to clients, we are pleased to offer the following intra-session communication options:
* Between each session your counselor will be pleased to accept and read one therapeutic email exchange without additional fees.
* A therapeutic email exchange is defined as an email to the counselor and their reply to you.
* Additional therapeutic exchanges will be provided for $32 per exchange.
* Scheduling or billing issues will not be considered therapeutic exchanges and are always free of charge.
All therapeutic emails must be directed to your counselors email address directly. All therapeutic email exchanges must be sent from your personal email address (for your own privacy, do not use a shared or
business email). While there is an expectation of privacy in your email communication with us, you must maintain common-sense security of your account. Four Peaks Counseling Services, PLC, nor any therapist in our practice, is not liable for any exposure of your information caused by breeches in security. While we will maintain strict privacy policies to keep your information private on our end, email communication should not be considered perfectly secure and does not comply with HIPAA standards. Email responses should not be used in cases of an emergency. Please allow 48-72 hours for response time from your therapist (although, it may often be sooner).

FEES AND PAYMENT FOR SERVICES
The initial session’s fee is $175. The current fee for additional standard 45-50 minute sessions is $150 and $175 for a 90 minute session or family session. Payments for services are expected at the time of service and will be collected prior to the session beginning. Four Peaks Counseling Services reserves the right to change fees at a later date; however, advanced notice will be given to you.

We will bill your insurance company directly for all in-network claims. Please take time to familiarize yourself with your insurance plan’s benefits. If you have any questions or concerns about your benefits, please contact your insurance company directly. Additionally, we are able to provide you with a monthly statement to submit to your insurance company, if requested for out of network claims. This receipt will include the dates of sessions, charges and payments, as well as all codes that are necessary for insurance reimbursement. However, it is NOT our responsibility to file claims on your behalf for out of network services, or to confirm if your insurance company will reimburse you for our services. Therefore, please familiarize yourself with your particular plan and benefits, as you are ultimately responsible for the full session costs. It is recommended that you contact your insurance company directly to inquire about services covered out of network, the number of sessions covered, and the estimated time for reimbursement to be received by you.You will be provided with these costs prior to beginning therapy, and should confirm with your insurance if part or all of these fees may be covered.

You should also know about the following:
• No-Show and Late Cancellation Fees
• CANCELLATION POLICY
* If you do need to cancel an appointment, please CALL to cancel as soon as you are aware of the need to do so. Once an appointment is scheduled, you will be expected to pay for it unless you provide a minimum of 24 business hours advanced notice of cancellation and/or rescheduling. Cancellations/rescheduled sessions with less than 24 business hours notice will be charged a fee of $25. No show sessions or less than one hour notice are charged the full session rate of $150 for a scheduled 45-50 minute session and $175 for a scheduled 90 minute session or family session. Payments for late cancellations/rescheduled and no show appointments fees will be charged to the card on file per your signed consent, and are to be made prior to being able to reschedule future visits. Please note, insurance companies will not provide reimbursement for cancelled or failed sessions; therefore, you will
be responsible for the full fee.
• Balance Accrual
• Full payment is due at the time of your session. If you are unable to pay, tell your Provider. Your Provider may offer payment plans or a sliding scale. If not, your Provider may refer you to other low- or no-cost services. Any balance due will continue to be due until paid in full. If necessary, your balance may be sent to a collections service.
• Administrative Fees
• Your Provider may charge administrative fees for writing a letter or report at your request; consulting with another healthcare provider or other professional outside of normal case management practices; or for preparation, travel, and attendance at a court appearance. Payment is due in advance. Your therapist is able to complete written treatment plans, summaries, and reports by request for an additional fee. The fees will depend on the amount of time required to prepare the required documents, but will typically range from $30-50. Four Peaks Counseling Services does not actively work with custody or legal cases. However, should you become involved in the legal process where your therapist is requested to testify or appear in court, we charge a retainer fee of $500 for their services. This fee will cover the first hour of an appearance at court and any preparation time spent on your legal case. A fee of $500 for each subsequent hour at the
same court appearance will then be charged. Payment is due in advance.
• Insurance Benefits
You are responsible to notify your provider of the decision to use your insurance benefits. You are also responsible for notifying your provider to any changes in your insurance benefits, as well as, all of your insurance benefit plans (primary and secondary plans).
• Before starting therapy, you should confirm with your insurance company if:
• Your benefits cover the type of therapy you will receive;
• Your benefits cover in-person and telehealth sessions;
• You may be responsible for any portion of the payment; and
• Your Provider is in-network or out-of-network.
• Sharing Information with Insurance Companies
• If you choose to use insurance benefits to pay for services, you will be required to share personal information with your insurance company. Insurance companies keep personal information confidential unless they must share to act on your behalf, comply with federal or state law, or complete administrative work.
• Covered and Non-Covered Services
• When your Provider is in-network, they have a contract with your insurance company. Your insurance plan may cover all or part of the cost of therapy. You are responsible for any part of this cost not covered by insurance, such as deductibles, copays, or coinsurance. You will be financially responsible for any services not covered by your insurance.
• When your Provider is out-of-network, they do not have a contract with your insurance company. You can still choose to see your Provider; however, all fees will be due at the time of your session to your Provider. Your Provider will tell you if they can help you file for reimbursement from your insurance company. If your insurance company decides that they will not reimburse you, you are still responsible for the full amount.
• Payment Methods
• The practice requires that you keep a valid credit or debit card on file. This card will be charged for the amount due at the time of service and for any fees you may accrue unless other arrangements have been made with the practice ahead of time. It is your responsibility to keep this information up to date, including providing new information if the card information changes or the account has insufficient funds to cover these charges.

COMPLAINTS
If you feel your Provider has engaged in improper or unethical behavior, you can talk to them, or you may contact the licensing board that issued your Provider's license, your insurance company (if applicable), or the US Department of Health and Human Services.