Self Pay Agreement Forms
As we move forward, it is absolutely essential that we make sure we have signed agreements from all clients that are self-pay, but who have insurance.
Clients may have to do self-pay because of insurance's policies regarding supervisory billing or for personal reasons, etc..If a client is self-pay but does NOT have insurance or we are out-of-network with their insurance (NOT including Medicaid), they do NOT have to sign an agreement.
The following Private Pay Agreements are now available in forms to email to clients:
Private Pay Agreement (Primary) - Opting to Not Use In-Network Insurance
Private Pay Agreement (Secondary) - Opting Not to Use In-Network Insurance
Private Pay Agreement (Primary) - Ins. with No Supervised Services - Medicare, United
Private Pay Agreement (Secondary) - Ins. with No Supervised Services - Medicare, United
Private Pay Agreement (Primary) - Ins. with No Intern Services - Kaiser, Providence
Private Pay Agreement (Secondary) - Ins. with No Intern Services - Kaiser, Providence
OHP CCO (Primary) - 30 Day Private Pay Agreement
OHP CCO (Secondary) - 30 Day Private Pay Agreement
In order to allow for sliding scales and differing fees, forms for Primary insurances have a section where the client will type in the agreed upon fee per service, so make sure you discuss this clearly with your client.
All of the insurance forms last for the duration of service unless revoked in writing by the client. EXCEPT, the OHP/Medicaid form. These forms only last for 30 days and then a new form MUST be signed in order for us to legally bill them.
It is VITAL that clients sign these forms in order to legally protect you and MTPNW. It is also important that I am informed of these clients so that I can ensure everyone has a signed form on file and that I can keep track. This is particularly the case for OHP/Medicaid clients as I will need to track the date the form is signed and resend/ensure the form is signed every 30 days.
As we move forward, please let me know of any and all clients that are currently self-pay or moving to self-pay so that I can make sure the appropriate forms are sent and that these clients can be recorded. You may send the form yourself if you'd like, but still let me know, please.
I have created a form for providers to fill out for all self-pay clients (who have insurance but are not using it).
https://forms.gle/E7ugf2eNT1NvGnm5A
If you have any questions, don't hesitate to reach out to me.
PS. If you spot any errors or weird things going on, please let me know! I tried my best to make sure all the forms were consistent and accurate but with all 8 forms, I'm bound to have made an error somewhere!
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Annie Burt
MTPNW Billing Department
Mindful Therapy Pacific NW, LLC4055 SW Garden Home Rd.
Portland, OR 97219