Lisa Heitmann, LCSW POLICIES AND INFORMED CONSENT CT Lic.# 004217
CONFIDENTIALITY STATEMENT: All information shared in this treatment is confidential except in circumstances governed by law. If you would like me to confer with another healthcare professional, you will need to sign a “Release of Information” form. This permission can be revoked by you at any time. You are also covered by HIPPA regulations, and you may view these rights as posted in my waiting room, or you may request a copy of your rights.
FINANCIAL POLICY: If you have insurance which provides coverage for this provider and this treatment, you may provide that information to me, and I will bill them. You will need to pay your co-pay amount at each visit. You are responsible for the full fee regardless of your insurance company’s reimbursement policies. Any additional professional services rendered by me at your request, such as phone contacts over 10 minutes, preparation of special forms, insurance reports, consults with other medical professionals, etc. will be billed at $150.00 per hour, and are not reimbursable by insurance. All court related assessments, depositions, letters, and appearances will be billed at $400.00 per hour, including travel.
FINANCIAL AGREEMENT: My fee for a fifty minute session is $135.00 individual, 165.00 for couples, payable at the time of treatment. You may pay by cash or check. If you do not have insurance, or are experiencing financial hardship, you may request a discount at this provider's discretion. Please initial the option you intend to use.
_________I intend to use insurance(Anthem BC/BS or Cigna ) and my co-pay per visit is $__________.
_________I intend to submit to my insurance via my out of network coverage, and will need a monthly billing statement.
_________I will not be submitting to insurance.
YOUR PAYMENT IS TO BE PAID IN FULL AT THE TIME OF EACH SESSION. Fees may be subject to change at any time, however, you will be given a six month notice of change should this effect you.
NO-SHOW AND CANCELLATION FEE POLICY: 24 HOURS NOTICE IS REQUIRED FOR CANCELLATION.
Your visit has been reserved for you. In order for me to assure your time, I am unable to schedule someone else in that time period. You will be responsible for paying the full fee (not just your copay) for any late canceled sessions. You may cancel by phone (860-742-1970) or email (email@example.com) Insurance will not pay for missed sessions. You will be expected to pay this fee at your next session unless other arrangements are made with me.
CANCELLATIONS: I appreciate as early a notice as is possible when cancelling, so I can schedule someone else in that spot. Typically when you cancel, your next session will be the following week at the same time. I do not generally return cancellation calls if I can. If you are an established client I will call you if I am unable to retain that spot for you. If you are a new client you will need to speak with me to reschedule an appointment.
WINTER STORM POLICY: I may be closed if the Mansfield School system is closed. If you are worried about driving in the snow or ice, and I am open, you may cancel without cost up to 2 hours prior to your appointment. Please call 860-742-1970 to do so.
EMERGENCIES: If you are in immediate crisis, you may call 211 (Info- line crisis line), or if it is a life threatening emergency, you should call 911 or go to your nearest emergency room. I will return regular phone calls as soon as possible, generally by the end of the next business day.
STATEMENT OF UNDERSTANDING: I have read the above and understand that by signing below I am agreeing to abide by these policies. Furthermore, I am voluntarily engaging in treatment with Lisa Heitmann, LCSW, and I understand that I may end treatment at any time.
Client Name (Printed) _________________________________________________Date: ________________