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Advance Potential Psychological Services, LLC

Please read the following important information. 

Eligibility for Service 
Mental health and chemical dependency services are not denied to any person on the basis of race, color, gender, sexual orientation, creed, handicap, national origin, duration of residence, or age. 

1. All services are provided by appointment. Following your initial interview, any additional appointments will normally be arranged and scheduled by office personnel at the front desk or your Therapist. 
2. Please check in with the office personnel and make any payments when you arrive for your appointment. Providers may choose to reschedule your appointment if co-payment/deductible is not paid. 
3. A 24-hour advance notice MUST be given for cancelled appointments. If you do not show up for your appointment as scheduled or you cancel with less than 24-hour notice, you will be charged $55.00 for the time reserved for you. Insurance companies will not reimburse for sessions that you do not attend. Payment will be expected on or before you next session. 
4. To schedule, change, or cancel an appointment, please call the office where your appointment is scheduled. If a receptionist is not available, you may leave a message on the confidential voice mail. 
5. Should you not schedule an appointment for a period of 60 days and no arrangement was made in writing with your provider for said time, you will no longer be considered an active client of APPS and will be determined to have terminated the counseling relationship. 

Payment of Fees 
1. Payment of fees should be made at the beginning of the scheduled appointment. Consistent payment must be made or services may be discontinued. 
2. If services are covered by insurance, APPS will bill your insurance company directly. It is your responsibility to inform APPS about any changes to insurance coverage, eligibility or personal address change. You are responsible to pay at the time of service any amounts due in order to cover any deductibles or co-payments that may be required by your insurance company. 
3. SECONDARY INSURANCE - APPS will only bill secondary insurance policies for the following insurance companies: Medicare and Medicaid. You are responsible for the secondary billing for all other insurance companies. 

NOTE - You may obtain the necessary information for secondary billing from your primary insurance carrier. 
4. If you have a balance on your account, you will receive a statement. All accounts are due and payable within thirty-days of notification. 
5. If you have questions regarding the payment of fees, please discuss this with your provider. Discuss with your provider any concerns or problems you have in paying your account BEFORE it becomes delinquent. 
6. If a client fails to be responsible for the account, and it is necessary to place a delinquent account into the hands of a collection agency/attorney, the client agrees to pay all court costs affixed by the court. 
7. Make checks payable to: Advance Potential Psychological Services, LLC 
8. There is a $21.00 service charge for NSF/Returned checks. 
In case of an emergency, there are several ways in which you can reach your provider. You may call the office, or you may call the 24-hour answering service and ask to speak with your provider. (24-hour answering service telephone number is (773) 512 - 8813. If your therapist is not available, another APPS provider will be contacted to assist you.) PLEASE USE THE ANSWERING SERVICE ONLY FOR CRISIS CALLS. 

Grievance Procedure 
You may discuss your grievance with your provider to resolve the problem/issue 
You may stop the grievance procedure at any point. If you wish to continue the grievance process: 
a. Complete the grievance form and/or contact the CEO (Grievance forms are available on the APPS website) 
b. Complaints will be reviewed by the APPS Grievance Committee within seven (7) working days to include final resolution presented to the person filing the complaint. 
c. No Smoking Policy: Beginning January 1, 2012, all office spaces of Advance Potential Psychological Services will be non-smoking. We care about your health, the health of others, and wish to promote healthy behaviors. All clients, staff, and providers are required to extinguish all smoking material prior to entering the grounds. If you attend group services at APPS, breaks will no longer be provided for smoking purposes. 

Client Endorsement 
By signing, you acknowledge that you have read the policy statement and understand all its provisions.

You may request a signed copy for your records. 

I have read all pages of this policy statement and understand its provisions. 

SIGNED: _________________________________________________________ DATE: _________________ 

SIGNED: _________________________________________________________ DATE: _________________ 

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