The following is important information for you to read and understand. Please inform me if you have any questions or concerns.
Conditions of Admission
If you use insurance to pay for counseling and I am an in-network provider with your insurance company, then your deductible, co-pay, and allowable sessions will be determined by your insurance company. You are responsible for fully understanding your mental health benefits.
If you would like to use insurance to pay for counseling and I am not an in-network provider with your insurance company, then you are responsible for the total cost of services. Payment is due at the time of service. I will give you a statement of services that you may submit to your insurance company and I will consider joining your insurance company’s provider network. Their determination of reimbursement to you is based solely on their discretion and is not the responsibility of Tony J. Himes.
Individual Therapy sessions are $70 to $125 per 50-minutes. Couple/Family rate $90.00 to $140.00 — 60 to 90 minutes. Family Consultation rate $15 to $25 per 15 minutes. Group Therapy rate is $100.00 to $125.00 per hour. Fees for non-standard sessions will be adjusted accordingly. Your insurance company may not cover the additional costs of longer sessions.
If you cannot attend a scheduled session, please notify me at least 24 hours in advance to avoid payment. Notification can be made by leaving a message at 777-9154. You will be charged $50 if you miss a scheduled appointment or cancel it less than 24 hours in advance. Please be aware that you are responsible for payment of late cancellation fees because insurance companies will not pay these fees.
Acknowledgement of receipt of notice of privacy practices
I acknowledge my receipt of “Notice of Privacy Practices” from Tony Himes’ office. I have read this document, clarified related questions/concerns, and understand its contents.
I voluntarily give consent Tony Himes to use or disclose the minimum necessary protected health information needed to operate his professional practices. This includes giving consent to Tony Himes to disclose the minimum necessary information to my insurance company, or its mental health component, in order to receive authorization and/or payment for professional services. I agree to the Conditions of Admission and understand the Notice of Privacy Practices.