The Rock Counseling Group - Champaign IL
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New Patient Information Form - Online Submission

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Please let us know your email address.
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In Case of Emergency:
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FEE AGREEMENT AND FINANCIAL POLICY

Thank you for choosing The Rock Counseling Group. Please review this Fee Agreement and Financial Policy. Please be sure you understand the policies regarding cancelations, missed appointments, payment methods, insurance reimbursement, and past due accounts. Please note this is not a comprehensive list  of services and fees, but reflects the most common services provided by our staff. Additional services may be recommended or required by your provider as deemed appropriate and will be discussed with you.

 

CHARGES NOT COVERED BY INSURANCE

Medical Records Requests and Printing $15.00 per request

Phone/Email/Text Message Consultations $175.00 (pro-rated per 15 min.)

Case Management $175.00 (pro-rated per 15 min.)

 

ADMINISTRATIVE FEES

Late cancelations/Missed Appointment – fewer than 24 hrs. prior to appointment $35.00

Non-sufficient funds (bounced) check $25.00

Past-due accounts – over 30 days $25.00 per month

Checks returned due to insufficient funds will incur a fee of $45.00

 

PAYMENT DUE AT TIME SERVICES PROVIDED

You will be expected to pay for either each session in full, or your insurance co-payment at the time of services provided under the Outpatient Services Agreement, which will be given to you along with this Agreement and Policy and our Notice of Privacy Practices. Accepted methods of payment are cash, check, or credit cards. Checks should be made payable to The Rock Counseling Group.

 

PAST DUE ACCOUNTS/COLLECTIONS

Amounts past due by more than 30 days will incur a late fee each month of $25.00. If your account has not been paid for more than 45 days and arrangements for payment have not been agreed upon, The Rock Counseling Group may resort to legal means to secure payment.

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THIRD PARTY INSURANCE FEE AGREEMENT AND AUTHORIZATION
The Rock Counseling Group accepts most major insurance plans and employee assistance programs. As a courtesy our staff will assist with obtaining an estimate of benefits available to you and filing claims with your insurance company. If you are using Third Party Insurance or Employee Assistance Plans to assist with payment for services, then we will:

Expect and accept payment of your co-payment, co-insurance, deductible or any out of pocket amount due at the time of service.

Expect that you will provide us the most updated information required to file claims including updated member identification numbers, policy numbers, and insurance provider information. Should you fail to provide updated information to us, we reserve the right to convert charges to self-pay rates and you will be responsible for the full fee of the services provided.

Expect that you will take responsibility to understand your health insurance coverage and obtain any pre-authorization requirements that your insurance may require. If your insurance plan requires an authorization for services to be initiated it is your responsibility to obtain the appropriate authorizations prior to your fist appointment. If authorization is required and not obtained we reserve the right to convert charges to self-pay rates and you will be responsible for the full fee of services provided.

If your insurance company denies a claim filed on your behalf, then you are responsible for full payment of the services provided by The Rock Counseling Group. Unless approved otherwise in writing by owners of the Rock Counseling Group.

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 $35.00.

PAST DUE ACCOUNTS & COLLECTIONS: Amounts past due by more than 30 days will incur a late fee each month of $25.00. If your account has not been paid for more than 45 days and arrangements for payment have not been agreed upon, The Rock Counseling Group may resort to legal means to secure payment. This may involve hiring a collection agency, an attorney or going through small claims court. If such legal action is necessary, you will be responsible for those costs.

I agree to:

(1) allow The Rock Counseling Group to bill my insurance directly for services provided under the Outpatient Services Agreement

(2) give The Rock Counseling Group permission to release any information the insurance company may require in order to process payment; appoint The Rock Counseling Group as my authorized representative to act for me in obtaining payment

(3) assign all of my rights to claims and payment by my insurance to The Rock Counseling Group. I understand that if my insurance plan requires that I meet a deductible amount prior to coverage by insurance, I will be responsible for the full session fee until the required deductible amount has been met.

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(Optional) AUTHORIZATION TO EXCHANGE AND RECEIVE PROTECTED HEALTHCARE INFORMATION

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I hereby authorize use or disclosure of protected health information including substance abuse/mental health records.

1. The person/group of persons/facility/or third part is authorized to use or disclose information about me

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2. The person/group of persons/facility/or third party who may receive dislosure of protected health information about me:

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5. I may revoke this authorization by notifying The Rock Counseling Group in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
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THIS FORM MUST BE FULLY COMPLETED AND SIGNED BELOW TO BE VALID:

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Counseling services

Children, adolescents, families, and individuals can all benefit from a helping hand and a listening ear at certain times that can help provide insight, support, and new strategies for all types of life challenges.

Executive

Even highly motivated, upwardly-mobile, educated, generally healthy people can sometimes use a helping hand to make their lives even better! The Rock helps you develop leadership skills that will not only grown your career, but enhance your life.

201 West Springfield Avenue, Suite 1201 Champaign, Il 61820

and

1002 Commercial Drive, Suite 2, Mahomet, Il 61853

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The Rock Counseling Group - Champaign IL

 

Proud Members of:

Champaign County Chamber of Commerce Member Mahomet, IL Area Chamber of Commerce Member Badge Champaign, Illinois West Rotary Membership The Rock Counseling Group