Financial
Responsibility Agreement
This Financial Responsibility Agreement (the “Agreement”) is made and entered into between Van Otto Counseling ("We", "Ours", "Us") and the client receiving mental health services or their personal representative (“You”).
BY CHECKING THE BOX “I AGREE” YOU INDICATE YOU HAVE READ, ACKNOWLEDGE AND AGREE TO THIS FINANCIAL RESPONSIBILITY AGREEMENT. IF YOU DO NOT AGREE TO THESE TERMS, YOU CANNOT ACCESS OUR SERVICES AND MUST EXIT NOW.
1. Your Responsibility for Payment. You are responsible for payment for all services provided by Van Otto Counseling. You understand that some services may not be covered by insurance. It is your responsibility to ensure your health plan benefits can be used for our services. To verify, please call the number on the back of your insurance card.
2. Services Covered by Insurance. Van Otto Counseling uses SonderMind for client and billing purposes. All billing is subject to SonderMind's Terms of Service. Clients will agree to SonderMind's policies when creating and agreeing to same.
3. Cancellations and No-Show Fees. If you cancel within the twenty-four (24) hours before the appointment, or if you fail to cancel the appointment and do not attend the appointment, you may be subject to a cancellation fee, up to the full cost of the session at the then current self-pay rate.
4. Billing. All insurance billing is processed through SonderMind and is subject to their Terms of Service.
5. Your Information. You agree to provide and update Van Otto Counseling with accurate personal information including but not limited to contact information and insurance information.
6. Collection Fees. In the event you have not made alternative arrangements for payment and this account is placed with an attorney or collection agency, you are responsible for collection fees, attorney’s fees, and court costs.
7. Credit Card Authorization. You understand that Van Otto Counseling may charge your credit card on file for financial responsibilities in connection with your care and treatment, including but not limited to any remaining balance, service fees, and appointment cancellation fees. THE CARDHOLDER NAMED ON THE CREDIT CARD ON FILE WITH VAN OTTO COUNSELING IS ULTIMATELY RESPONSIBLE FOR THE PAYMENT OF ANY OUTSTANDING BALANCE ON YOUR ACCOUNT.
9. Right to a Good Faith Estimate. If you are not enrolled in a health benefits plan, or choose to not use your health benefits to pay for therapy services with Van Otto Counseling, you have the right to receive a Good Faith Estimate for the total expected cost of services. Please submit your request for a Good Faith Estimate to vanottocounseling@gmail.com. If you receive a bill from us that is at least $400 more than the Good Faith Estimate, you can dispute the bill by emailing vanottocounseling@gmail.com. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 844-256-9902.
