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SEE OUR consents, notices and POLICIES BELOW
Additional Forms
Our Credit card policy
Our clients appreciate the convenience of using a credit, debit or health savings account to cover their portion of the medical costs. We take your card securely and notify you about any charges due after your insurance is applied.
As a service to our clients, we automatically submit your medical claim(s) to your health insurance company. When your insurance plan determines the amount that you owe as “patient responsibility,” we charge that amount on the card you provided.
If you owe any balance after your insurance pays, we will send you an email notification 10 days before your card is charged. The timing of this communication depends on how fast we hear back from your insurance company. It usually happens within 30 days of your visit, but it could take up to 90 days. If you owe any balance after your insurance pays, we will notify you within 90 days. If you do not have an email, we will send a letter that will arrive about 2 to 5 days before your card is charged.
If you do not want the credit card that was previously provided to be changed for any reason, please immediately contact our office at 574.651.8912 Option 0 to make other payment arrangements.
Cancelations & Missed Appointments
Insurance carriers will not pay for late cancelations or missed appointments. Once an appointment is scheduled, that time is reserved specifically for you. Cancelations must be made at least 24 hours in advance. Although 24 hours is the minimum, if you need to cancel or reschedule please give as much notice as possible. You may notify our office of cancelation by phone or email to your provider. Late cancelations (fewer than 24 hours before the appointment) will incur a fee of $50.00 that will be automatically charged to the credit card provided after failure to attend one scheduled therapy sessions for each missed session thereafter. Please be advised that two no shows or three late cancels for any provider will result in discharge from the practice.
MEDICARE PRIVATE PAY CONTRACT
As of January 1, 2024, Medicare began allowing Licensed Counselors to become Medicare providers. At this time, Cornerstone Family Therapy has chosen to opt out of Medicare. Our current opt-out period runs from January 2, 2024 through January 2, 2026.
We made this decision because Medicare is new for counselors, and there is still a lot to learn about the ins and outs of billing, coverage, and the different plan types. Until we receive more education and have a full understanding of how Medicare works for mental health providers, we believe it is best to remain opted out.
What this means for our Medicare clients:
Private pay contract required – Any Medicare client who wishes to receive services with us must sign a private-pay contract before beginning treatment.
Full responsibility for payment – Medicare will not reimburse you for services, and you will be responsible for the full cost.
No Medicare limits – We are not bound by Medicare charge limits; fees are set directly between you and our practice.
No secondary coverage – Medigap or supplemental plans will not cover services provided under this contract.
Your choice – You may receive services from us as a private pay client, or you may choose another provider who participates with Medicare.
Because Medicare opt-outs are set in 2-year periods, we cannot make any changes until our current period ends in January 2026. At that time, we will re-evaluate our decision.
Enhancing Your Experience with Heidi Health
At Cornerstone Family Therapy, we utilize Heidi Health, a HIPAA-compliant audio-to-transcript note taking service, during sessions to enhance your experience. This service acts as a scribe, allowing our therapists to focus fully on your needs without the distraction of notetaking.
Heidi Health does not collect or store audio recordings; instead, it generates temporary transcripts that are used solely for creating session notes and documentation. Not all therapists use this service, and if your provider does, you have the option to decline its use at any time.
For more information please see the document below.
Because the clinician-client relationship is so important to us, we assign cases according to your needs and the specialty of our therapists in the most cost-effective way possible. For this reason, it is extremely important that you complete the form in its entirety and have the most up to date insurance information available. Once we receive this form below, an intake packet will be sent out to you through our online client portal.