Fee Agreement and Financial Policy HIPAA Compliant Bonmente’s Fee Agreement and Financial Policy describes our schedule of fees for services, charges not covered by insurance, and additional fees. Please be sure you understand the policies regarding cancellations, missed appointments, methods of payment, insurance reimbursement, and past due accounts. If you have any questions about anything, please ask our administrative staff prior to signing this Agreement and Policy. Payment You will be expected to pay for either each session in full, your insurance co-payment, and/or deductible or co-insurance at the time of services. Accepted methods of payment are checks or credit cards. We will use the card on file to process payment at the time services are rendered. Referrals: Failure to secure a referral or authorization will result in your responsibility to pay the self-pay rates. Insurance Reimbursement for Services Bonmente accepts insurance plans from a variety of providers. If you are using insurance or employee assistance provider to pay for our services, then we will: Expect and accept payment of your copayment amount at the time of service; File your claim with the insurance provider; Receive payment from your insurance provider; Expect that you will pay your portion due of copay, co-insurance, deductible, or fee difference at the time of your appointment. Note: Bonmente files insurance as a courtesy to you, but you (not your insurance company) are ultimately responsible for your bill. If your insurance company denies a claim filed on your behalf, then you are responsible to pay Bonmente for the difference between the standard rate and the amount previously paid as copay unless approved otherwise by Bonmente. In the event that you miss up to two payments you may be discharged from Bonmente for failure to adhere to our financial policies. If your insurance status changes, you must present your new insurance card/information at or prior to the time of your next appointment, or you may be responsible for the full cost of the appointment. You agree to: Allow Bonmente to bill your insurance directly for services; Give Bonmente permission to release any information the insurance company may require in order to process payment; Appoint Bonmente as your authorized representative to act for you in obtaining payment; Assign all of your rights to claims and payment by your insurance to Bonmente; Agree to assist with the claims process as required by Bonmente or your insurance provider. If your insurance plan requires that you meet a deductible amount prior to coverage by insurance, you will be responsible for the full session fee until the required deductible amount has been met. You acknowledge that not all issues, conditions, and problems dealt with in psychotherapy are reimbursed by insurance companies. If you do not have insurance and plan to self-pay for services at Bonmente, you agree to the fee schedule in this document and understand that payment for services is due at the time services are provided. Patients that ignore or fail to meet their financial responsibilities for rendered services may be discharged from our practice for failure to adhere to our financial policies. Service Rates This is not a comprehensive list and reflects the most common services provided by our healthcare providers. Additional codes may be used by your provider as deemed appropriate. The service codes that are billed to your insurance company are at the discretion of the healthcare provider and the level and complexity of your care. Note: If your insurance pays for the appointments, your financial responsibility will be for the copayment, deductibles, and co-insurance for your appointment and rates will be as per contracted agreement with your insurance provider. The following are the self-pay rates in the event your insurance company does not cover your services (i.e. out of network, no mental health coverage, and termination of benefits) and administrative fees that are not covered by your insurance company: Initial Medication Management Consultation Individual (60min): $350.00 Follow-Up or Level 5 (60) One-Hour Evaluation: $300.00 Follow-Up (45) Forty-Five-minute Evaluations: $250.00 Follow-Up (30) Thirty-minute Follow-up Evaluation: $200.00 Follow-Up (15) Fifteen-minute Evaluation: $150.00 Initial (60) Therapy Consultation: $250.00 Follow-Up Therapy Follow-up: $150.00 Phone Consultations (11-60 min.): $100.00 (prorated per 15 min.) Initial Disability Forms: $500.00 (Depends on approval after 4th visit by the provider) Disability Extension Forms: $250.00 FMLA Forms: $200.00 LOA Forms: $200.00 ESA Letter: $150.00 a maximum of 2 pets per letter Fee for Forms: $50.00 per form-per request (documentation of treatment, employer treatment, and general treatment letters) Patient Self Pay The following are reasons why you may elect to self-pay for services rendered: You agreed to self-pay due to the fact that we are out of network with your insurance company. You agreed to self-pay due to inactive insurance. You agreed to self-pay due to the lack of telehealth coverage. This means that at the time of service, you will be paying by check or debit/credit card. Due to this payment arrangement, you are receiving a discount. We will not bill insurance for services provided under this agreement. No forms will be produced now or in the future for you or for us to submit for insurance billing. When you become a patient with Bonmente, you acknowledge: I understand that I will be responsible for all charges related to the services provided to me by Thomas Health Services DBA Bonmente. I understand that the charges presented to me are due in full on the day of service unless arrangements have been made with the Billing Manager in advance. I understand that in case I file for reimbursement/s with my insurance, the self-pay rate will still be my full financial responsibility regardless of the amount my insurance has approved. I have read and fully understood the above self-pay rates, and I agree to waive insurance billing. I also understand that I will be responsible for paying for the services rendered to me and/or my dependent. Cancellations and Missed Appointments Due to the time-intensive nature of consultations, Bonmente requires a 24-hour notice for patients to cancel a scheduled appointment. Under such a policy, the patient who fails to give appropriate notice for canceling an appointment will be responsible for a late cancellation or a no-show fee. Insurance carriers will not pay for late cancellations or missed appointments. Once an appointment is scheduled, that time is reserved specifically for you. Cancellations 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 cancellation by phone or email to your provider. If there are two or more missed appointments without 24 hours’ notice within a 6-month period, please understand this may lead to termination from the practice. Bonmente provides courtesy reminders via email and phone to confirm all appointments before your scheduled time. Providing the required notice allows us to schedule patients from our waiting list in the event your appointment is rescheduled or canceled. Note: Courtesy calls are just that—a courtesy. Not receiving a reminder call does not change the no-show/late cancellation policy. Your credit card on file will be charged on the day of the missed appointment. Our Late Cancellation/No Show Fees and Policy is as follows: New Patient Appointments require 1 Business Day notice (24 Hours) or will incur a fee of $175.00 Follow Up Appointments require 1 Business Day notice (24 Hours) or will incur a fee of $100.00 Therapy Visits require 1 Business Day notice (24 Hours) or will incur a fee of $125.00 Follow-up One-Hour Appointments require 1 Business Day Notice (24 Hours) or will incur a fee of $175.00 If you are unable to keep an appointment because of a sudden illness or an unexpected personal emergency, notify our office at (310) 360-7200 or email our office at contact@bonmente.com as soon as you know you will not be able to attend your appointment. The missed appointment fees are charges your insurance company is not responsible for and will not pay for; they are your financial obligation. If you are requesting to waive your fee for a late cancellation/missed appointment because you were ill, we will require a physician’s note or documentation for the request to be considered. Patients who fail to pay the no show fees will not be allowed to schedule future appointments until the fee is paid or payment arrangements are made. Multiple late cancellations or no shows will result in dismissal from our practice. Bonmente is committed to helping you with your mental and behavioral needs. Financial Responsibility and Payment Policy Patients are responsible for timely payment of their balances, including: Co-pays, deductibles, and non-covered services. Outstanding balances must be resolved promptly to continue care. Failure to address unpaid balances may result in referral to collections and/or suspension of services. If you are experiencing financial hardship, we encourage you to speak with our billing department to explore available options or payment plans. Card on File & Automatic Payment Authorization I authorize Bonmente to securely store my credit or debit card and charge outstanding patient balances of up to $250 per transaction, including deductibles, copayments, coinsurance, and non-covered services. Bonmente will provide notice by email and/or text at least three (3) days before charging my card, including the amount and scheduled payment date. I may contact Bonmente with questions or disputes before the scheduled charge is processed. I understand that I remain responsible for all amounts owed if my card is declined, expired, or otherwise unavailable. I may revoke this authorization in writing for future charges, but revocation will not affect previously processed charges or existing balances. Past Due Accounts Policy Our Past-due Accounts Fees and Policy is as follows: Any account over 30 days past due is subject to a $25.00 late fee charge. Disability Forms Processing Policy Due to the high volume of work and time needed to complete the disability forms, Bonmente generally does not complete disability forms. However, Bonmente has the following policy to assist in rapidly processing disability forms when indicated. All paperwork that is processed will take 3-5 business days from the date received to complete and mail or enter the claim into the state disability portal. Paperwork cannot be processed unless you have completed all portions of the documents that are to be filled out by the patient. All signature areas must be completed. A copy of the forms will be uploaded to your chart after the healthcare provider has signed the forms, and it will remain a part of your permanent record. New patients requesting state disability forms, life insurance forms, and private insurance disability forms will require a $500.00 processing fee for the initial forms and $250.00 for the extension and/or subsequent forms. If you are an existing patient and your provider determines you will need disability forms completed, it will require a $350.00 processing fee for the initial forms and $225.00 for the extension or subsequent forms. Please be advised that Bonmente reserves the right to determine if a short-term disability is medically appropriate. Short-term disability is determined by your provider, and it can be anywhere from 1 week up to 6 months of disability. If you are on disability, you will be required to schedule weekly medical management and therapy appointments potentially. Paperwork will not be processed without payment in advance. We accept credit cards and checks. Please make checks payable to Bonmente. The insurance companies do not reimburse our healthcare providers for administrative functions; therefore, you shall be responsible for payment for disability forms processing. We appreciate your assistance in completing your portion of the forms. This policy is to better serve you, our patient. If you have any questions or concerns, please feel free to contact our office. Medication Refill Policy Our office has a firm policy that we will not provide refills outside of a 30-60 day supply. (This includes all medications including any controlled medications that are prescribed). Due to the current DEA and pharmacy regulations our office requires a mandatory 30 day follow up appointment for controlled medications. Respectful Conduct Policy At our practice, we are committed to creating a safe, respectful, and supportive environment for all patients and staff. As part of this commitment, we ask all individuals to adhere to the following policies: Respectful behavior is expected at all times. We maintain a zero-tolerance policy for any form of: Rude, aggressive, or hostile behavior Threatening or intimidating conduct Profane or inappropriate language Discriminatory or harassing remarks Visibly using a vape pen containing THC resin during a session, it will trigger a review of our best practices and ethical guidelines for providing remote therapy. Attending appointment(s) intoxicated (e.g., from alcohol or other substances), and reports their intoxication during the session, the session may be adjusted or discontinued. Patients who do not follow treatment agreements, are non-compliant, or are deemed inappropriate for telepsychiatry will be referred for different levels of care or discharged. Any such actions may lead to immediate dismissal from the practice and potential reporting to appropriate authorities if warranted. The therapeutic alliance relies on mutual trust and respect—violations compromise the safety and integrity of the care environment. No Surprises Act – Good Faith Estimate You have the right to receive a Good Faith Estimate explaining how much your medical and mental health care will cost. Under federal law, health care providers must provide a Good Faith Estimate of expected charges to patients who are uninsured or who choose not to use their insurance (self-pay) for scheduled services. You have the right to receive a Good Faith Estimate for the total expected cost of any scheduled, non-emergency health care services provided by Bonmente, including psychiatric evaluations, medication management, psychotherapy, and other behavioral health services. You may request a Good Faith Estimate before scheduling a service or at any time before receiving services. If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill through the federal patient-provider dispute resolution process. Be sure to save a copy of your Good Faith Estimate. For more information about your rights under the No Surprises Act and Good Faith Estimates, visit https://www.cms.gov/nosurprises.
