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Financial Policy

This statement is to inform you of RoxAnne Koenig, MS, LIMHP financial policy. I am committed to providing you with the highest quality mental health care. My financial policy is intended to facilitate excellent service to you, while minimizing administrative costs.

All charges incurred are your responsibility regardless of your insurance coverage. I must emphasize that as your provider, my relationship is with you, my client, not with your insurance company. As a courtesy to you, I will help you process all your insurance claims. In order for me to help, you must provide current and accurate insurance information.

I understand and agree:

• RoxAnne Koenig, MS, LIMHP performs services necessary for the wellbeing of her clients regardless of insurance benefits.

• Regular therapy services are billed at: Initial session ($260) Individual ($200) Family ($200)

• My co-pay, deductible, or self-pay fee is due at the time of service. It is ultimately my responsibility to know what my copay and deductible are prior to services. If I need help with finding out what these copays and deductibles are, RoxAnne will help to try to find this information out from the insurance but she cannot guarantee these amounts.

• If there is a remaining balance upon payment by the insurance company, I will pay it in full at that time.

• I am responsible for the payment of all treatment fees on my account. If my insurance company fails to pay, I will be responsible for the full amount.

• A late fee of $10 will be added to overdue accounts each month.

• A $35 fee will be added for any return or insufficient fund checks written to RoxAnne Koenig, LLC

• Accounts over 90 days will be sent to a collection agency and will have additional fees.

• RoxAnne Koenig, MS, LIMHP requires a 24-hour notice for cancellations. When scheduling your appointment with the counselor, keep in mind that this is your agreement that the counselor will hold this time exclusively for you. Because this time is reserved by you, RoxAnne Koenig, MS, LIMHP will bill you $50 for any appointments that is not kept and $45 for appointments canceled or rescheduled less than 24 hours advance notice. I understand that insurance companies DO NOT get billed and will NOT pay for these fees. These will be paid by the client. Payment for late cancellation, fail to arrive charges, and return checks are due at the time of your next session.

If you have questions regarding my financial policy, please ask. I am committed to providing you with the most positive experience.

Signature Date:

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