Fee Schedule

Two Week Treatment Program for Children/Family and Adult/Couple

Application Fee (applied towards treatment if accepted into program)
$250.00

Clinical Fees (a team of psychotherapists)
$10,500.00

Note: 50% deposit due when scheduling treatment; remainder due on first day of treatment.

Hometown Therapist (supervision provided during treatment)
No Charge

Follow-Up Consultation (with parents and hometown therapist)
No Charge

* Transportation and lodging not included.

* Visa and MasterCard accepted.

Insurance Coverage For Intensive Outpatient Psychotherapy

Insurance coverage varies for our Intensive Outpatient Psychotherapy program (IOP). Some insurance companies and plans have paid 100% of the clinical fees, others have paid a percentage, and others have not provided any reimbursement. If your carrier refuses coverage, you can initiate an appeals process.

We will bill for clinical fees "out-of-network," under Evergreen Psychotherapy Center, PLLC (EPC).

1. Talk to someone in a position of responsibility with your insurance company and explain what services you are requesting.
   
   
2. Get preauthorization if necessary.
   
   
3. Determine the amount they are willing to pay.
   
   
4. Clarify billing requirements, if possible; CPT code, per individual, per family. Convey this information to us.
   
   
5. Request the agreement in writing, if possible.

The following are the responsibilities of EPC:

1. Explain our treatment program to your insurance company, if necessary.
   
   
2. Pre bill or bill afterward, as per their instructions. We will provide you with a copy of all billing statements.

We do not guarantee payment by any insurance company or 3rd party, and are not responsible for such negotiations. Payment of treatment fees: A non-refundable deposit of 50% is due at the time of scheduling, which guarantees your treatment time. The remaining 50% is due on the first day of treatment.

NOTE: Any contracts that we have with insurance companies pertain to outpatient psychotherapy only, not to our two-week IOP. The IOP program is considered out-of-network.

I have read the above Client Agreement regarding Insurance Coverage for Intensive Outpatient Psychotherapy and understand and agree to abide by the terms as set forth within.


Client: _____________________________ Date: _______________________


Client: _____________________________ Date: _______________________


Therapist: __________________________ Date: _______________________

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