This document outlines the office policies and procedures for Harbor Psychological Services, PLLC. To receive services, you’ll need to review and agree to these policies. If you have questions, please ask before signing. By signing, you confirm that you have read, understood, and accepted the terms in this document.
You can withdraw your consent for treatment at any time by submitting a written request to Harbor Psychological Services, PLLC. However, this financial agreement will still apply to services provided before your consent was revoked. Additionally, if any services are required after you terminate treatment—such as legal documentation or reports requested by third parties—this agreement will still govern those charges.
GOOD FAITH ESTIMATE: Under the No Surprises Act, you have the right to receive a Good Faith Estimate outlining the expected costs for psychological services. The estimate is based on the information known to Harbor Psychological Services, PLLC when the estimate is provided. Although these estimates provide you a general guide for anticipated charges, estimates may change based on various factors, including, but not limited to, changes in insurance benefits, insurance adjustments or denials, changes in identified clinical needs, and changes in time or materials required to provide your services. If your final bill is $400 or more above the estimate, you can dispute the charges. You can ask the provider to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS), as detailed in the separate Good Faith Estimate form.
FULL PAYMENT POLICY: Payment is required in full before services are provided. If you are using insurance and there is a balance after adjustments or denials, you must pay the balance within 30 days of billing. Balance is not paid within this time will be considered overdue and can be sent to collections or pursued through other legal channels.
CREDIT CARD ON FILE AND AUTHORIZATION TO CHARGE CARD: All clients must have a valid credit card on file through SimplePractice before scheduling services. Payments are securely processed through Stripe. You agree that you have read and understood terms and conditions documentation from SimplePractice and Stripe and you agree to using SimplePractice and Stripe to process your payments. Providing your card information means you agree to automatic payments for co-pays, deductibles, and any remaining balances after insurance processing. Your card may also be charged for no-shows, late cancellations, or rescheduling fees as outlined in our cancellation policy. It is your responsibility to update your card information if it changes. A 20% late fee will be applied to declined payments each month, and unpaid balances may be sent to collections after 90 days.
THIRD-PARTY BILLING SERVICES: Harbor Psychological Services, PLLC partners with Professional Data Management, Inc., a third-party billing company, to handle insurance claims and payments. By receiving services, you agree that necessary billing information can be shared with Professional Data Management, Inc. and, when required, with SimplePractice. You agree to allow Harbor Psychological Services, PLLC to share necessary information about your services with Professional Data Management, Inc. and SimplePractice to the extent required to file insurance claims, respond to inquiries from your insurance company, appeal insurance company decisions, provide information about delinquent claims to third-party collections agencies, and share any other information required to process claims and payment. Both Professional Data Management, Inc. and SimplePractice have signed Business Associate Agreements (BAA) to ensure compliance with HIPAA regulations. If you’d like a copy, please submit a written request.
You understand that Professional Data Management, Inc., SimplePractice, or Harbor Psychological Services, PLLC will contact your insurance company to ask questions about your coverage, or may need to call you or contact you directly to discuss your account.
You understand that verifying your benefits does not always guarantee coverage. Payment and coverage are determined by multiple factors after the claim is filed. Harbor Psychological Services, PLLC offers no guarantee of insurance coverage under any circumstances. You will receive billing statements for your services as necessary to process your claim and obtain payment. Payment must be made via SimplePractice or to Professional Data Management, Inc. by the due date.
RESPONSIBILITY FOR ALL CHARGES: This agreement confirms your financial responsibility for all services. You agree that you are responsible for all fees to Harbor Psychological Services, PLLC in the event of insurance adjustments to your claim or denial of your claim.
Before scheduling, verify your insurance benefits for psychological services. While we file claims as a courtesy, it is your responsibility to understand your coverage, including any prior authorizations or limits. You authorize us to file claims on your behalf and assign insurance benefits and payments from your insurance company directly to Harbor Psychological Services, PLLC.. You are required to pay any applicable co-pays, insurance, or deductible portion in full at the time service. If you pay out-of-pocket or use out-of-network benefits, payment in full is required at the time via your credit card on file with SimplePractice. If you need a superbill, we’ll provide one upon request, but you must handle any insurance claims or reimbursement. Failure to pay all charges in full at the time of service will result in your appointment being canceled and a cancellation fee automatically charged to your credit card on file. Appointments canceled under the circumstances will not be rescheduled.
You are responsible for providing accurate and complete information about your insurance plan to Harbor Psychological Services, PLLC. You also must immediately inform Harbor Psychological Services, PLLC of any changes in your insurance coverage. You understand that a claim may be processed differently from what was expected and result in a higher out-of-pocket expense to you. You understand your insurance company may deny a claim entirely, leaving you responsible for the full balance. Any remaining balance is your responsibility. You agree that any balance remaining after your insurance company has paid their portion will be automatically charged to your credit card on file. If insurance doesn’t pay within 30 days, you must pay any outstanding charges. Failure to pay on time may result in your account being sent to collections or legal action.
By signing this document, you are agreeing to the disclosure of confidential information where such disclosure is necessary to obtain certification, authorization, or payment for your services, or where we are required to disclose information by the terms of our contract with your insurer or managed-care company. For example, your insurance company may require details about your condition or treatment in order to cover your treatment. You authorize Harbor Psychological Services, PLLC to pursue appeals and grievances with your insurer or managed-care company when necessary to obtain payment for your insurance claim or when we believe an appeal of denial of care by your insurance company is appropriate or necessary.
CODING AND BILLING POLICY: We bill insurance claims accurately and follow industry regulations. If there is an error on our end, we will correct and resubmit the claim. If an insurance company error occurs, we will request that the insurer reprocess the claim. We are required to use accurate billing and diagnosis codes, and we cannot modify them to ensure insurance payment. Some codes may not be covered, and if that’s the case, you are responsible for the cost. To avoid surprises, verify your insurance coverage before scheduling.
APPOINTMENT RESERVATION FEE AND POLICY: Due to a multitude of factors that must be considered when providing psychological services, no one is guaranteed an appointment. Harbor Psychological Services, PLLC reserves the right to review circumstances for each appointment request to ensure that there is no conflict of interest or other factor that interferes with the ability to provide appropriate psychological services to you.
When you schedule an appointment, that time is reserved specifically for you. To hold your spot, we reserve the right to require an appointment reservation fee, which will go toward your balance when you attend. If you cancel with less than 48 hours’ notice, arrive more than 10 minutes late, or fail to show up, the reservation fee is non-refundable and is charged to your credit card on file. This policy helps ensure that appointments remain available for clients who need them.
STANDARD FEES: Standard fees for the services we offer are detailed below, but are subject to change. You are responsible for ensuring you understand the fees you will be charged for your services. Fees are the same for in-person and telehealth services.
Diagnostic Interview (one hour): $200
Psychological Testing Packages: Rates vary by assessment package and will be provided before you schedule your appointment.
Psychological Testing, A La Carte: $200 per hour, including face-to-face testing time AND time required for record review, scoring, interpretation, and report writing.
Interpretation/Feedback Session (one hour): $200
ADDITIONAL FEES (CONSULTATION, PHONE CALLS, PAPERWORK) : You will be billed for any additional services not covered by insurance benefits or for services beyond your initial service and fee agreement or good faith estimate. These services may include, but are not limited to, writing letters, completing phone calls, providing consultation, additional report or letter writing, or any other service requested beyond the initial service and fee agreement and good faith estimate. These services are billed in 15 minute increments, at $25.00 per 15 minutes, and will be automatically charged to your credit card on file.
RECORD COPY FEE AND MEDICAL RECORDS REQUESTS: To cover the time and effort required to prepare records, a fee of fee of $0.50 per page will be charged, with a minimum fee of $15. Requests have a turn-around time of 21 business days. Harbor Psychological Services, PLLC does not complete forms that fall outside standard billing or service documentation, such as Disability Determination forms, Family Medical Leave forms, Worker’s Compensation forms, Employee Assistance forms, or any other forms not agreed upon in advance.
MISSED APPOINTMENTS AND LATE ARRIVALS: Although Harbor Psychological Services, PLLC may offer appointment reminders, it is your responsibility to remember and attend your appointment. If you agree to appointment reminders, you agree we may contact you at any contact information you provide, including email, voicemail, or text. You agree that we may leave an appointment reminder message with a responsible party in your household, unless you specifically request us not to do so. A nonrefundable $150 fee will be automatically charged to your credit card on file for late arrivals (more than 10 minutes past your appointment time), missed appointments, or cancellations made with less than 48 hours’ notice. Missed appointments will not be rescheduled.
POLICY ON FINANCIAL RESPONSIBILITY AND COMMUNICATION FOR DIVORCED OR SEPARATED PARENTS OR LEGAL GUARDIANS:
Both parents or guardians must consent to treatment for a minor child or dependent adult; however, only one party will be designated as financially responsible. That individual will sign this Financial Agreement and handle all payments. Harbor Psychological Services, PLLC will not divide invoices or mediate disputes between parents or legal guardians. It is your responsibility to obtain any reimbursement due to you by any other party, such as in the case of divorced or separated parents sharing medical expenses for a minor child. Any financial disputes must be resolved independently.
The party signing this Financial Agreement agrees to be fully responsible for all charges as detailed in this agreement. In addition, the party signing this Financial Agreement is responsible for providing all billing documentation to any other party as required. If a non-responsible parent or legal guardian requests billing information from Harbor Psychological Services, PLLC, we will review the request and comply with applicable laws, but we will not routinely provide duplicate billing documentation.
REFUNDS: Harbor Psychological Services, PLLC does not provide refunds for any services rendered, unless you are due a refund because of overpayment, such as through insurance company reimbursement or pre-payment credits to your account.
COURT FEES: Harbor Psychological Services, PLLC does not provide custody or legal evaluations, recommendations, or consultations. I will not appear in court on your behalf, nor provide any documentation for any custody or other court related proceedings. If I am subpoenaed at any time to appear in a court action for legal matters in which you are involved, the party signing this Financial Agreement will be responsible for all associated charges at the rate effective when the request or subpoena is received. Rates are subject to change. The party signing this Financial Agreement is responsible for these charges, no matter who issues the subpoena. Collections will be pursued to the fullest extent of the law. You agree to abide by all policies detailed in the separate Non-subpoena Contract and Court Policy Agreement
OVERDUE BALANCES: Balances must be paid within 30 days of billing. After 30 days, we reserve the right to charge your card on file, refer the account to collections, or take legal action. A late fee of 20% may be added for each additional 30-day period past the due date. Accounts unpaid for 90 days may be sent to collections, and you will be responsible for any additional collections or legal fees associated with collecting the money you owe to Harbor Psychological Services, PLLC. Harbor Psychological Services, PLLC reserves the right to cancel any and all appointments if payment is not received at the time of service.
RIGHT TO WITHHOLD REPORTS: Harbor Psychological Services, PLLC reserves the right to withhold full psychological reports until all fees are paid in full. In the rare event of a life-threatening emergency that requires immediate release of psychological assessment results, information will be released as necessary to meet the emergency need. In addition, if you require your test results in order to receive life-sustaining medical treatment, even if the circumstance is not considered an immediate life-threatening emergency, results will be released as necessary to ensure that you may obtain such medical treatment.
EMAIL COMMUNICATION AND EMAIL FORWARDING: Even if you choose not to use electronic communications, I may at times be required to use email or to forward email, such as billing inquiries or insurance-related questions, to a third party billing company, payment processor or other parties for billing, payment, or other administrative purposes. You agree to allow Harbor Psychological Services, PLLC to communicate by email or to forward email as required for such billing or administrative purposes.
COMMUNICATION WITH REFERRING PARTIES: If another provider, such as your physician or other healthcare provider, referred you to us, we may update them on your treatment progress to ensure coordinated care. If you prefer that we do not share certain information, you are responsible for notifying Harbor Psychological Services, PLLC in advance regarding information you want withheld from any referring party. Fees for these communications are listed in the Additional Fees section.