Practice Policies

Policy

 Melanated Womens Health, LLC
1500 Walnut Street 
Philadelphia, PA 19102

If you are seeking coverage for sessions through Victims Compensation Assistance Program (VCAP) funding, it is your responsibility to submit the claim form. For this funding and for reimbursement, I am asked to provide an itemized receipt. This receipt may include, but is not limited to, your name and address, my information, session dates, CPT codes, diagnosis codes, and amount charged. This receipt will be sent to VCAP at a weekly or monthly interval. You will be responsible for the full cost of services that are not reimbursed by VCAP.

Melanated Womens Health, LLC will do its best to verify insurance benefits as part of the intake process. However, as the client, you understand that while your insurance company may confirm your benefits, “confirmation of benefits is not a guarantee of payment” and that you are responsible for any unpaid balance.

Your Therapist and the Administrative Team will do their best to help with questions about coverage, but there might be times when clients are asked to call their insurance company directly. You understand that it is your responsibility to know if your insurance has any deductible, copayment, co-insurance, prior authorization requirements, or any other type of benefit limitation for the services you receive and you agree to make payment in full.

You also agree to inform the practice of any upcoming changes in your insurance coverage. The practice will check new benefits for any change in coverage. However, if your insurance has already changed or is terminated at the time of service, you agree that you are financially responsible for the balance in full.

If your account balance has not been paid for more than 60 days and arrangements for payment have not been agreed upon, Melanated Womens Health LLC has the option of using legal means to secure payment. This may involve hiring a collection agency or going through a small claims court which will require your Therapist to disclose otherwise confidential information. In most collection situations, the only information released regarding a patient’s treatment is name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim.

APPOINTMENTS AND CANCELLATIONS

Please remember to cancel or reschedule 24 hours in advance. You will be responsible to pay a $95 fee if cancellation is less than 24 hours. This fee is not covered by insurance.
The standard meeting time for psychotherapy is 53 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 53-minute session needs to be discussed with the therapist in order for time to be scheduled in advance.
A $10.00 service charge will be charged for any checks returned for any reason for special handling.
Cancellations and re-scheduled session will be subject to a $95 fee if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you will lose some of that session time.

OTHER CHARGES

Court related charges are the responsibility of the client/parent/guardians making the request or whose attorney makes the request. Before your Therapist will engage in any court related activity, a minimum non-refundable retainer of $1000 must be paid.
Court related activities including time spent responding to requests for information, phone contacts (prorated to the nearest minute), preparing for court or traveling more than 10 miles one-way from the office to court are billed at $300 per hour and charged against the retainer.

Therapist attendance at court interferes with a Therapist’s ability to be available to their clients. In the event your Therapist is required to appear in court on behalf of you or your child, there will be a charge of $2,000 payable by cashier’s check or credit card at least 7 business days prior to the court date.

We do not voluntarily testify in court cases. Should a case be rescheduled or continued for any reason, your Therapist will be paid in full for each day. If your Therapist must clear their calendar to appear in court again, you will be charged the full fee. If your court date is cancelled, the fee is non-refundable.

Requests for production of medical records or charts has a charge of $1.60 per page in addition to a flat rate of $155 for the time taken to compile the records.

TELEPHONE ACCESSIBILITY

If you need to contact your Therapist between sessions, please leave a message on their voice mail. Your Therapist may often not be immediately available; however, your Therapist will attempt to return your call within 24 hours. Please note that Face- to-face sessions are highly preferable to phone sessions. However, in the event that you are out of town, sick or need additional support, phone sessions are available. If a true emergency situation arises, please call 988 or any local emergency room.

SOCIAL MEDIA AND TELECOMMUNICATION

Due to the importance of your confidentiality and the importance of minimizing dual relationships, Your Therapist will not accept friend or contact requests from current or former clients on any social networking site (eg., Facebook, Instagram, TikTok, etc). Engaging with clients as friends or contacts on these sites can compromise confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. You may follow social media accounts that are open to the public, but do not comment or in any way identify yourself as a client of Melanated Women’s Health LLC or one of its associate Therapists because these sites will compromise your confidentiality and our respective privacy. It may also blur the boundaries of the therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

ELECTRONIC COMMUNICATION

Your Therapist and the Administrative Team cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, your Therapist will do so. While your Therapist may try to return messages in a timely manner, an immediate response cannot be guaranteed. It is recommended that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
Telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that:
(1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
(2) All existing confidentiality protections are equally applicable.
(3)Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee.
(4)Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent. If you are interested in recording any part of our session(s), either through video or audio means, I require a written request. Recording and sharing a telemedicine session without a written consent can result in termination of the therapeutic relationship and legal actions. Likewise, a Therapist would need to provide you with a written request to record sessions if they need to do so for educational purposes. If this is the case, your written consent is required and you would be provided a detailed form for you to give consent or withhold consent.
(5)There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist’s inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he/she/they would consider important information, that you may not recognize as significant to present verbally the therapist.

MINORS

If you are a minor (i.e., younger than 14 years old), your parents are legally entitled to some information about your therapy. Your Therapist will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

TERMINATION

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. Your Therapist may terminate treatment after appropriate discussion with you and a termination process if it is determined that the psychotherapy is not being effectively used or if you are in default on payment. Your Therapist will make every effort to first discuss termination of the therapeutic relationship with you, and explore the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, you will provided a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.
Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.

BY STARTING SERVICES I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

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