Outpatient Services Contract Summary

Welcome to Hope Springs Behavioral Consultants! The following information is a summary of important points in the Outpatient Services Contract (HERE). When you sign this contract summary, it will represent an agreement between yourself and Hope Springs Behavioral Consultants. If you have questions about our polices or procedures, please ask your provider.

Our front desk is open Monday – Thursday 9am to 4pm and Friday 9am to 12pm. Provider hours will vary.
Clients are seen by appointment only. We do not have after-hours, urgent, or on-call services. If you have an urgent matter, please contact your primary care physician or emergency services.

You authorize Hope Springs Behavioral Consultants to submit claims on your behalf. We require payment at the time of service for out-of-network clients, co-payments, co-insurance, and deductibles. For parents with shared custody, the parent that brings the child to the appointment is responsible for payment. Insurance policies vary, and they do not always cover services. It is your responsibility to know what services your insurance covers prior to services rendered.

In order to better serve our clients, we have implemented a cancellation policy. If you are unable to make your appointment, please notify us at least one day in advance to cancel your appointment. If the appointment is not cancelled or you do not attend your scheduled appointment, you will be charged a fee according to our out-of-pocket fee schedule. If you incur three no-shows in a twelve-month period, you may be discharged from the practice.

We want everyone to stay safe and healthy! In the case of inclement weather or illness, you will not be charged a fee, but please try to give us notice that you will not make it to your scheduled appointment.

Children under the age of thirteen cannot be left alone in the waiting room. Our front desk is not responsible for watching your child(ren). You must give written permission if anyone other than a parent/guardian attends session.

We will use e-mail, text, and phone calls to communicate with you regarding scheduling or to answer your questions. There could be privacy risks associated with e-mail and text correspondence. You may opt-out at any time.

For charges that are not billable to insurance, we have an out-of-pocket fee schedule. We charge for missed appointments, phone calls, letters, forms, and records requests. We can keep a credit card on file, but our system is not automatic. If we do not charge your card on the date of service for any reason, you may be sent an invoice for the charges and will need to pay upon receipt. If you do not pay your statement, your care may be terminated, and charges may be sent to collections after ninety days

Providers at Hope Springs reserve the right to terminate care if the provider (or staff) is treated disrespectfully, or if the provider is unable to meet the client’s needs.

Providers at Hope Springs are mandated reporters. By law, we are required to report emotional, verbal, physical, or sexual abuse of a minor or vulnerable adult.

Your signature below indicates that 1) you have read the information in this form as well as our Outpatient Services Contract document and agree to abide by its terms during our professional relationship; 2) you have reviewed and/or have been offered a copy of the Hope Springs Behavioral Consultants HIPAA privacy information form (HERE); 3) you authorize Hope Springs Behavioral Consultants to bill your insurance for your services.

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