Informed Consent

Informed Consent to Treat & Service Fees

Credentials:  We are licensed to practice in the State of Kansas as a licensed therapist in our field of specialty.  We are not medical providers or medical doctors and do not give medical advice or prescribe medication.

 

Hours:  By appointment only.  Appointments are generally available between 9am and 8pm Tuesday through Thursday; 10am to 4:30pm on Saturday and Sunday; closed on Monday and Friday. 

 

Confidentiality:  All information disclosed within sessions, including that of minors, is confidential and may not be revealed without written permission except as required by law.  Disclosure may be required in the following circumstances:

  1. Where there is a reasonable suspicion of child abuse or abuse to a dependent or elder adult.

  2. When the client communicates a threat of bodily injury to self or others.

  3. A medical emergency when the health of the client is in jeopardy.

  4. When the disclosure is ordered by a court.

 

Cancellation:  A scheduled appointment reserves a time slot specifically for you.  In a sense you are buying that time.  To avoid being charged for a missed session, please inform me of a cancellation at least 24 hours in advance.  Late cancellations may be charged at the full fee.  They are not reimbursed by insurance companies and therefore are out-of-pocket.

 

Use of Health Insurance:  Insurance coverage is an agreement between you and your benefit carrier to pay some of your bill.  You are responsible for the payment of your bill regardless of the status of your insurance claim.  We do not become involved in disputes between you and your insurance company or another party about payment of costs.

 

Referral:  If a referral from a primary care physician or lock-in provider is required for your insurance, it your responsibility to obtain this referral prior to services being provided.  Likewise, if a referral from an insurance or managed care company is required for services to be covered, it is your responsibility to obtain such referral or authorization.

 

Payment of Fees:  In order to provide therapeutic services for a reasonable fee, The Next Chapter does not utilize an outside billing service.  Our expectation is that patient fees will be paid at the time of service however we understand that life happens.  Continuity of care is important for your healing and growth so please talk to your clinician about payment arrangements if necessary.  All payments received from client, insurance or other funding resources will be applied as rendered to the corresponding outstanding charges.  Upon fulfillment of the outstanding balance due (including co-payments, deductibles, and non-covered services by insurance) any overage paid by the client or responsible party will be refunded in the form of a check within forty-five (45) days of completion of services. 

 

Fee Schedule:  The fees charged are typically the community average for psychotherapy services.  Your insurance carrier may have negotiated a discounted fee on your behalf.  We are willing to negotiate out-of-pocket fees for those who do not have insurance or do not wish to use it.

300 W. Douglas, Suite 205

Wichita, Kansas 67202

Call Us:

316.759.9136

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