Fees, Insurance and Payments Statement

Effective Date: [March 5, 2025]

DNP Psychiatry - A Professional Corporation - www.dnppsychiatry.com

Fees, Payment & Insurance

DNP Psychiatry ("we," "as," or "our") excepts a wide range of insurance providers including Aetna, Pacific source, Regents Blue Cross/Blue Shield, Providence, Moda, Pacific source, Kaiser, Optum, Medicare, and Medicaid.

If DNP Psychiatry is not in network with your insurance provider, and you have out of network benefits, we can assist in processing your claims directly with your insurance. We can review and discussion of benefits and the anticipated cost associated with treatment.

Understanding the complexities of insurance coverage and mental health services can be overwhelming. Our knowledgeable staff is here to guide you through the process and answer questions you may have regarding your specific insurance plan.

At DNP Psychiatry we will help you verify your coverage and explain any co-pays, deductibles, or other fees associated with your insurance plan, allowing you to make informed decisions about your mental health care.

At DNP Psychiatry by accepting the above listed insurance plans we aim to provide comprehensive psychiatric services to a wide range of individuals and families in the Oregon community. Our experienced and compassionate team are here to help the payment and insurance process proceed smoothly.

At DNP Psychiatry we also offer cash pay rates for individuals not using insurance or who want to submit claims on their own. We can provide you with a detailed statement, or superbill, for services that may be covered by your insurance as out of network benefits. A superbill contains all the necessary information for you to submit a claim to your insurance company for reimbursement.

DNP Psychiatry has implemented the policy where most patients are required to have a payment method on file at the beginning of each appointment. This policy is designed to streamline billing processes, save time and stress for all. We do not accept cash payments. Credit card options may include Health Savings account (HSA), Health Reimbursement account (HRA), Flexible spending account (FSA), Debit card, and Credit card. Co-pays where applicable will be collected and insurance claims billed. Patients agree to pay outstanding balances, including but not limited to co-payments and co-insurance amounts, self-pay fee schedule amounts, no-show/cancellation fees, other administrative fees and any balance remaining after insurance reimbursement relating to services provided to the patient.

If DNP Psychiatry is processing an insurance claim and once the insurance company has processed the claim, they will send the patient an explanation of benefits (EOB) detailing their

Meeting you where you are in mind, body and spirit - guiding along the way
financial responsibility for the services received. DNP Psychiatry will also receive a copy of the EOB. Patients typically receive it before we do. If the EOB indicates a balance owed, then that payment should be made immediately via the patient portal.

Primary Payment Responsibility. Patients agree to pay DNP Psychiatry for all charges incurred for services DNP Psychiatry rendered and assign to DNP Psychiatry any monies due and owing under their health insurance plan or other third-party payor, including government payors, worker’s compensation payors, personal injury case defendants, and medical benefits accident insurance payors. Patients are informed and agree that DNP Psychiatry may amend the fee schedule and its Terms of Service from time to time in its sole and absolute discretion and without prior notice but understanding it will be available on the company’s webpage or upon request.

Patient Responsibility and Commitment, Cancellations and Missed Appointments. Patients understand that it is their responsibility to ensure their health plan benefits can be used for DNP Psychiatry services. To verify, please call the number on the back of their current insurance card. All DNP Psychiatry invoices for services and costs are due upon receipt, and all copay, coinsurance, and deductible amounts are due at the time service is delivered or post claims adjudication.

At DNP Psychiatry patients understand that it is important to show up for their appointments with their treating clinicians, and to show up on time. A minimum of one (1) business days’ notice is required to avoid any fees for cancelled and missed appointments. If this notice is not received or if the patient fails to show for the appointment within the first fifteen (15) minutes of a scheduled therapy appointment or five (5) minutes of a scheduled medication appointment, the Patient agrees to be personally responsible for payment for the full amount for the time reserved for the appointment. Patients agree to and understand their obligation to pay the Late Cancellation/No Show Appointment fee stated in the State-Specific Addendum to their Patient Services Agreement. Patients have agreed to grant DNP Psychiatry the right to charge their credit card on file for that fee if applicable.

At DNP Psychiatry patients understand that health insurance does not pay for fees incurred for missed appointments. If unforeseen situations beyond their control arise, such as illness, bereavement, and accidents, etc., the patient has agreed to promptly provide DNP Psychiatry Health with documentation of same to avoid being billed for the full amount of the fee.

Third-Party Payors. Patients understand they are responsible for all monies due and owing for services rendered by DNP Psychiatry that are not paid by a third-party payor. It is ultimately the patient’s responsibility to ensure that any third-party payor covers, and makes timely payment for, DNP Psychiatry services. If any monies received by DNP Psychiatry from a third-party payor are later recouped from DNP Psychiatry any time after their receipt, the patient agrees to

Clinic. Patients agree that if they receive a bill from DNP Psychiatry that is at least $400 more than the Good Faith Estimate, they can dispute the bill by calling DNP Psychiatry’s Office. For questions or more information about patient’s rights to a Good Faith Estimate, please visit www.cms.gov/nosurprises or call 844-256-9902.

Off-Label Treatments and Tests. Many clinically appropriate medications, assessments or treatments are not currently FDA-approved or are considered experimental by third-party payors and may not be reimbursable from third-party sources. Patients consenting to these services understand and agree that DNP Psychiatry has the right to charge their credit card on file for all services not covered by third-party payors at the time of service or upon notice of denial of payment by a third-party payor.

Full Coverage for Testing and Assessments. Coverage and cost for psychological and psychiatric assessments and tests vary across different third-party payors, and patients have been informed and agree to be responsible for the costs for the tests regardless of whether the costs are reimbursable by third-party payors. This is because not all psychological testing services are covered by third-party payors. Patients have been informed that third-party payors do not fully reimburse psychological testing services, even if provided by an in-network provider. There are a variety of situations when this occurs; for example, when: (a) the third-party payor does not consider psychological testing “medically necessary” for “experimental” or “investigational” diagnoses; or (b) when the third-party payor reimburses for fewer hours than billed by DNP Psychiatry. Patients consenting to these services understand that they will be fully responsible for payment of all services upon service delivery or upon notice of denial of payment by a third-party payor. Patients grant

DNP Psychiatry the right to charge their credit card on file for all requested services or tests not covered by third-party payors at the time of service or upon notice of denial of payment by a third-party payor.

Collections. Patients agree that if their account is turned over to an attorney or agency for collection, they agree to pay all costs of collection including, but not limited to, court costs and legal and collection fees. If their account is not paid when due, a service fee and/or interest will accrue as permitted by law.

Forensic Legal Requests. Patients understand that forensic legal requests, conferences, and telephone calls involve additional time and record-keeping for DNP Psychiatry, and patient agrees to be responsible for all direct costs and expenses incurred by DNP Psychiatry, and its attorneys and agents, in responding to discovery requests (including depositions and subpoena duces tecum time and labor costs) and relating to conferences (including, but not limited to, court appearances, preparation of reports, photocopying, faxes, long-distance telephone calls, out of office travel, overnight delivery, and courier services). Patients grant DNP Psychiatry the right to charge their credit card on file for all such requested forensic legal services and documentation time.

Assignment of Benefits. All patients acknowledge and agree that DNP Psychiatry may receive payments directly from any third party for the non-covered health care services provided by DNP Psychiatry. Patients agree and authorize DNP Psychiatry to release any information needed to determine benefits payable by a third party or their agents. If the patient receives any payment from a third party for a non-covered health care service, the patient agrees to turn over the payment in full to DNP Psychiatry. In addition to assigning all payments to DNP Psychiatry for services rendered, patients hereby agree to assign all of their related rights and obligations under their insurance plan to DNP Psychiatry and its representatives, grant this limited power of attorney, including specifically the right to file claims, litigate and appeal claim denials and pursue causes of action under the Employee Retirement Income Security Act (ERISA) or other laws. Patients hereby permit a signature on file or copy of this Agreement to be used in place of their original signature.

Health Savings Account. Per IRS regulations, if a patient participates in a high-deductible health plan with a health savings account (HSA) feature, the patient may be required to pay a fair market value fee for certain available non-preventive and urgent services until their deductible has been satisfied. Patients understand that if they have an HSA and they do not pay on a fee-for-service basis for these services, they may lose their ability to contribute to their HSA.

Patient’s Accurate and Current Insurance Information. All patients agree to provide and update DNP Psychiatry with accurate personal information including but not limited to contact information and insurance information. A patient’s failure to update their information may result in denied payments or inaccurate charges.

Fees:
Psychiatric Evaluation (60 minutes): $350.00
Psychiatric Follow up (30 minutes): $175.00
Telephone Consultations (Billed in 15-minute increments): $200/Hr

Please contact DNP Psychiatry by phone (458) 250–4964 or by mail at 175 W. B St., Springfield, OR 97477 with questions about this fees, payments and insurance statement.

Warm Regards,

Don Cleland, DNP, APRN, PMHNP-BC, FNP-BC, PHN, RCP
Director, DNP Psychiatry, PC

Meeting you where you are in mind, body and spirit - guiding along the way