Terms of service.
Fee Schedule
All services are the consumers’ (patients/clients) financial responsibility, regardless of whether consumers plan to use insurance benefits or HRA plans. All fees (copays, deductibles, coinsurances) are due upfront before the session starts. A credit card on file must be kept or a form of payment/deposit agreed upon with Cheryl Lopez, LCSW Psychotherapy Services, PLLC.
Full Service Fees (excludes insurance discounted amounts)
$250 Initial Diagnostic Evaluation with measurements, self-assessment scales (Standard 60 to 75 min Session)
$200 Individual session (Standard 50 to 60 min Session)
$250 Couples/Family session (Standard 50 to 60 min Session)
$175 Follow up Session (Standard 40 min Session)
$175 Coaching Call (30 min Session)
Cheryl Lopez, LCSW Psychotherapy Services, PLLC asks that if you need to cancel your appointment, you let the practice know at least 24 hours before your appointment to ensure the session is available for other consumers who need an additional session time.
Insurance cannot be billed for missed sessions. Therefore, a full fee is applied if cancellation policy is not met. This fee is implemented at the discretion of the practice, emergencies, and other unexpected events can be waived if it is not persistent and a continuous pattern. Please direct all questions to Dr. Lopez, not the administrative staff.
100% Full Rate (Late appointment cancellation- less than 24 hours)
If you are unable to pay the rate at the time of service for more than one visit, without developing a payment plan, future appointments will be suspended until unpaid balances are resolved.
Sliding Fee Schedule available for individuals without insurance in need of services (evaluated by case to case basis with criteria to indicate need).
Cancellation Policy
If you are unable to attend an appointment, we request that you provide at least 24 hours advanced notice to our office. Since we are unable to use this time for another client, please note that you will be billed for the entire cost of your scheduled appointment if it is not timely canceled, unless such cancellation is due to illness or an emergency.
For cancellations made with less than 24-hour notice (unless due to illness or an emergency) or a scheduled appointment that is completely missed, your card on file will be charged the full session fee.
We appreciate your help in keeping the office schedule running timely and efficiently.
Consent for Treatment and Limits of Liability
Limits of Services and Assumption of Risks:
Therapy sessions carry both benefits and risks. Therapy sessions can significantly reduce the amount of distress someone is feeling, improve relationships, and/or resolve other specific issues. However, these improvements and any “cures” cannot be guaranteed for any condition due to the many variables that affect these therapy sessions. Experiencing uncomfortable feelings, discussing unpleasant situations and/or aspects of your life are considered risks of therapy sessions.
Limits of Confidentiality:
What you discuss during your therapy session is kept confidential. No contents of the therapy sessions, whether verbal or written may be shared with another party without your written consent or the written consent of your legal guardian. The following is a list of exceptions:
Duty to Warn and Protect If you disclose a plan or threat to harm yourself, the therapist must attempt to notify your family and notify legal authorities. In addition, if you disclose a plan to threat or harm another person, the therapist is required to warn the possible victim and notify legal authorities.
Abuse of Children and Vulnerable Adults If you disclose, or it is suspected, that there is abuse or harmful neglect of children or vulnerable adults (i.e. the elderly, disabled/incompetent), the therapist must report this information to the appropriate state agency and/or legal authorities.
Prenatal Exposure to Controlled Substances Therapists must report any admitted prenatal exposure to controlled substances that could be harmful to the mother or the child.
Minors/Guardianship/Temporary Foster-Guardianship Parents or legal guardians or temporary Foster-Guardianship of non-emancipated minor clients have the right to request access of the clients’ records. Records are limited to chart summaries/letters per request (with client’s consent).
Insurance Companies
To ensure insurance or third-party payers are given information they need always request consumer’s identifying information like name address, diagnosis, type of services provided to the consumers (clients and patients). This may be due to preauthorization and request for initial and on-going services like additional extension of time and treatment plan parameters. Please note that Cheryl Lopez, LCSW Psychotherapy Services, PLLC Reserves the Right to limit amount of information of requested to protect confidentiality of the consumer. Clinical case notes are limited to date of service requested or treatment plan range.
Limits of Release of Information
The type of information that may be requested by insurance includes types of service, dates/times of service, diagnosis, treatment plan, description of impairment or disturbance of functionality in Personal/ Work/ Family/ Social/ Daily Living Activities/Relationships etc, the progress of therapy, case notes, summaries, etc. Such information will not include specific names or situations that can jeopardize confidentiality and therapeutic alliance. In addition to this the practice does not provide copies, clinical case notes with disclosing information. Such information is limited to any party including the consumer.
Consumers can request for other documentation to filled out for their employer like a letter, additional work accommodations and short term/long term disability. This requires proper consent and details of who and where paperwork is being disclosed to. consumer must review paperwork with provider prior to release to ensure documentation is releasing the privacy and limits of their consent.
To protect the privacy, resilience, survivors of trauma, it is essential to support the consumers in protecting privacy and agency. Any clinical case notes are not considered paperwork will not be disclosed or provided.
Consumers may request a discharge summary or letter but case notes will not be provided.
For more complex legal situations, testimony, letters may be warranted and must be discussed privately and agreed upon between parties and fees applied.
Under no circumstances will individual clinical notes be provided as it is unethical and privacy issues for Cheryl Lopez, LCSW Psychotherapy Services, PLLC.
Not all services offered by Cheryl Lopez, LCSW Psychotherapy Services, PLLC are covered by insurance. If consumers (“clients” or “patients”) desire to use their insurance plans, then they are required to take extra steps before scheduling a session. It is important to note that regardless of coverage consumers are responsible for fees and determination of plan benefits. Therefore if the group practice is not in network with some insurance plans it is important for consumers to verify if Cheryl Lopez, LCSW Psychotherapy Services, PLLC is covered by their group insurance plan under the practice’s NPI # 1184223224.
If not, then consumer's must determine if they have Out-Of-Network Benefits and if they can OR will pay out of pocket expenses.
Those individuals who self pay and don’t use insurance don’t require cpt code: diagnosis to be submitted to their insurance plans.
If Yes, then consumers must provide consent, insurance plan details and a form of payment for fees and deductible (if payment is submitting paperwork on their own then they will receive a statement at the end of the month of paid dues).
Once determined payment plan and schedule an appt for initial evaluation to attain a diagnosis and treatment plan for insurance.
Sessions must be medical necessary and have a CPT diagnosis code and full diagnostic evaluation and paperwork. In order to attain reinbursement they mst be submitted for final approval and can be provided in form of statement with CPT code. Regardless of whether services are not deemed covered it is the consumer (patient or sessions or services are the client or patient’s financial responsibility. Fees that are not covered by insurance, are charged at full fee (unless granted negotiated insurance discount) along with additional fees like 3rd party billing 2%, tax 8.875% and credit card fees 4.5% adding to total fee.
Please note insurance panels do not guarantee coverage as they have to authorize medical necessity and plans must include mental/behavioral health coverage.
You have the option to pay out of pocket and deal directly with your insurance group as you are the member with more access and rights. Insurances have the right to deny coverage or not cover mental health, psychotherapy, which is why Cheryl Lopez, LCSW, Psychotherapy Services, PLLC collects 100% of the discounted contracted insurance panel fee.
All fees are due before the session unless it is agreed upon before the start of services between you and the provider. It is the consumers’ responsibility to submit appropriate documentation in a timely manner so authorization and documentation can be submitted for payment or reimbursement. If the consumer does not meet those guidelines then their insurances have the right to deny coverage.
Therefore Cheryl Lopez, LCSW Psychotherapy Services, LLC reserves the right to charge full fee of out of network services and for those in network it must be confirmed and agreed upon prior to initating services. Invoices can be billed on weekly/biweekly/monthly sessions, credit card and tax fees applied so it can be submitted in timely manner.
Consumers’ insurances in network with group practice are not required to pay in full but must pay copay/coinsurance at time of insurance until insurance pays for session. If explanation of benefits returns that consumer is responsible then full balance of negotiated insurance panel rate balance is charged directly with card or payment on file (taxes and credit card fees applied). To ensure the estimated amount of negotiated fee for insurance panel discounted rate please contact the office your insurance and verify with Cheryl Lopez, LCSW Psychotherapy Services, PLLC to confirm the negotiated rate.