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Client and Family Responsibilities

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Client and Family Responsibilities

Cancellation of Appointments and Discharge:

  • Twenty-four hour notice must be given when cancelling or rescheduling an appointment.
  • Discharge of a client shall occur when the client’s symptoms have been ameliorated and the client has agreed that there is no further medical necessity for treatment to continue.
  • If the client is not “at risk,” and he/she fails to attend three appointments without contact within a six month period, (or) the therapist has not had any contact with the client after 30 days, the client may be discharged. If the client is considered to be “at risk,” the therapist will contact the case manager or family member to assist in setting up additional services.
  • If the client is misusing or abusing medications which is prescribed by an ACE physician, he may be subject to immediate discharge.
  • If the client has consistent mismanagement of medications or theft of his prescriptions, he may be subject to immediate discharge.
  • If the client displays inappropriate behaviors when in the office which impedes on the therapeutic experience of others, the provider has the right to discharge.

Copays, Deductibles, Payment Plans:

  • Copays and deductibles will be collected prior to services being rendered.
  • Clients can be refused services if they are unable to pay for copays or deductibles at the time services are rendered.
  • Payment plans will be available to those clients who have a balance that exceeds $80. Clients with balances less than $80 will be required to make payment in full prior to services being provided. Clients will be required to pay 20% of the balance (in addition to the copay, if applicable) at the time services are rendered.
  • A credit card is required to be kept on file for all self-pay balances. Services can be delayed or terminated at the agency’s discretion if a client is unwilling to provide a credit card on file.

Fees for services (Out-of-pocket):

Clients who would like to receive services but do not have active or in-network insurance may pay for services out of pocket using the following fee schedule:
Individual therapy with non-licensed clinician (1 hour): $90
Individual therapy with licensed clinician (1 hour): $115
Medication check with psychiatrist (In-person): $90
Medication check with psychiatrist (telepsychiatry): $125
Psychiatric Evaluation: $225
EMDR with licensed clinician (1 hour): $225

Request for Medical Records:

  • Clients may have access to his/her records upon request. Access does not imply physical possession of the medical record but rather a review of the record.
  • Access may be denied when it is determined that disclosure of the specific information will cause a substantial detriment to the client’s treatment or when the disclosure of specific information will reveal the identity of persons or breach the confidentiality of other person who has provided information upon an agreement to maintain their confidentiality. Access may be denied if it is necessary to protect an individual’s privacy or the security of the health information. Access may be denied if it is not possible due to infeasibility of the record request or if IT temporarily being unavailable or if the request would degrade health IT’s performance.

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  • Clients may have access to the appointment record, medication list, treatment plan, safety plan, HIPAA disclosure, and an authorization to release information without additional fees.
  • Multiple copies of documents may incur a charge of $0.50 per copy.
  • Clients who request review of paperwork for FMLA or work disability (Short-term or long-term) by a physician must be in services with ACE for a minimum of one year to consider processing paperwork. The physician holds full discretion to determine if completion of paperwork is medically necessary. Requests for completion of disability paperwork may take up to 7-10 business days for processing.

Social Security Disability Applications:

  • Patients must be in treatment for a minimum of one year in order for an application to be reviewed by the psychiatrist.
  • The treating psychiatrist reserves the right to deny applications in the event that the psychiatrist believes the patient is able to hold employment.
  • It is recommended that patients who are seeking a more immediate results would consult with a Disability Lawyer or visit to gain additional information.

Client Grievance Procedure:

  • All clients or family members may initiate a complaint orally or in writing to an ACE staff member. The complaint shall be presented as soon as possible to the Executive Director. All clients and family members are permitted to have a witness present when providing a complaint.
  • The Executive Director shall investigate the complaint and obtain a resolution. A resolution will be provided in writing within 48 hours after the complaint has been filed. This document will be mailed to the client and filed in the medical record.
  • At any time, clients are able to make a complaint directly to his/her insurance company. ACE will comply with any requests made by the insurance companies or legal governing agencies that may be involved in the grievance process.
  • The client or representative may appeal the grievance decision within 10 days of the decision.
  • Once the written appeal has been received, the Executive Director will meet with the treatment team to review the appeal. The treatment team will determine if an additional internal investigation is required. If immediate action is required, the treatment team may contact the insurance company’s grievance department for resolution assistance.
  • Appeals will not jeopardize the continued treatment of the client unless otherwise requested by the client or it is determined that a referral should be made due to the nature of the complaint.
  • If an additional internal investigation occurs, the client will be provided with an updated resolution within 48 hours of the appeal. This document will be mailed to the client and filed in the medical record. If an outside investigation is conducted by an insurance company, ACE will cooperatively work with the insurance company to complete the appeal procedure.
  • The second appeal may be requested by the client and the appeal procedure may be repeated. ACE will comply and make every effort to resolve the second appeal and cooperate with the insurance company

By signing below I have read, understand and agree to follow the Client and Family Responsibilities.

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