Financial Consent & Insurance Billing

I voluntarily consent on behalf of myself or my legal dependent to participate in evaluation, consultation, and/or treatment as a patient of Sol Mental Health. I give my authorization to receive treatment and I understand that developing a treatment plan with my clinical team and regularly reviewing our work toward meeting goals is in my best interest. I agree to play an active role in this process and understand that I may address any concerns with my clinical team in a timely manner. I understand that no promises have been made to me as to the results of treatment or of any procedures provided by Sol Mental Health. I am aware that I am free to choose treatment and may stop treatment at any time. I understand that if I choose to stop treatment, I will still be financially responsible for the services I have already received. 

This agreement shows my commitment to pay for the treatment I receive. I agree to pay for the services rendered at each session or in accordance with an established payment plan. Insurance may cover part, or all the cost of treatment, and I understand that Sol Mental Health will attempt to charge the correct copay or allowable amount at time of service. However, I understand that it is my responsibility to check my coverage and be knowledgeable about my benefits. I also understand that there may be some types of treatment that may not be covered by insurance but may be clinically recommended. Unless otherwise specified, by me, I agree to allow submission of insurance claims to insurance (if appropriate) – this includes diagnoses and treatment information. I authorize payment of benefits to Sol Mental Health. 

Fee Policy

I understand that I must call to cancel an appointment at least 48 hours (2 business days) before the appointment time (weekend days and holiday days do not count towards the minimum 2 business day requirement). If I do not cancel or do not show up, I will be charged $100 for individual appointments and $50 for group appointments. I agree to pay for appointments that are not canceled or those where I fail to give proper notice that I will not attend. Certain exceptions for unforeseen or unavoidable situations can be made at the exclusive discretion of Sol Mental Health. I understand that insurance does not pay for appointments that are not canceled, so I will be solely responsible for the cost. If it becomes apparent during a telehealth appointment that you are traveling and located in a state your clinician is not licensed in, your appointment will be ended and you will be charged the no show rate. Fees will also apply to late arrivals and requests for abbreviated appointments. 

Telehealth Behavioral Contract 

  1. Confidentiality cannot be guaranteed by the clinician in a virtual platform. You understand that you need to be in a quiet, private setting wherein they will not be overheard and can speak freely. 
  2. You understand that telehealth services bring with them the risk of technological difficulties and Sol Mental Health will do everything possible to address any issues on our end during a session. Sessions will not be extended due to technological difficulties. You understand that you have the responsibility to ensure a good connection is available for your appointment times. 
  3. Your clinician must know your location during every telehealth session. You agree to provide your address or location for these sessions. You agree to inform the clinician if this changes at any point throughout your care. I understand that Sol Mental Health cannot provide virtual care to patients that are located out of state at the time of the telehealth appointment. You will be charged a late-cancel / no-show fee if you arrive for a virtual appointment while traveling out of state and the clinician cannot see you due to licensure requirements. 
  4. You agree to take telehealth sessions seriously and present as you would in an in-person session. This includes, but is not limited to, being on time, having devices turned off, being appropriately dressed, and focusing fully on the session. You agree that you will not use substances during a telehealth therapy session. 
  5. Teletherapy sessions may be discontinued at any time by the clinician or by the patient if these standards are not met. 

Treatment Expectations 

  1. Initial consultations are for purposes of diagnosis and evaluation only; an initial evaluation may not necessarily constitute the creation of a treatment relationship 
  2. Your clinician may require more than one appointment to complete your evaluation; this may happen for various reasons, including but not limited to, if: more information is required, we need to contact past and/or current clinicians to gather supporting information, or additional testing or laboratory work is needed 
  3. We do not routinely provide prescriptions at the end of the first consultation 
  4. There are times when we will only be able to work with you when you give us permission to receive healthcare information from past and current clinicians 
  5. SOL Mental Health utilizes a team-based model. You may be seen by a clinician [including but not limited to a therapist, psychologist, nurse practitioner (NP), or physician assistant (PA) who is under the supervision of a physician (MD or DO)]. In these cases, your care will be supervised by the physician who will be credentialed with your insurance company and who will be listed as a ‘supervising provider’ on your insurance claim. 

Treatment Agreement 

  1. Clear and timely communication is essential for proper clinical care 
  2. Please follow-up promptly with evaluations necessary for your care (such as, but not limited to, laboratory testing, psychological testing, medical evaluations, specialist referrals, etc.) 
  3. In order to assure adequate continuity of care, your clinician will meet with you regularly; please let us know if you have questions about this. We cannot provide care to patients who are unable or unwilling to meet at a clinically appropriate frequency in the clinician’s best judgment for standard and customary care.