Heart Mind Body, LLC

Financial Agreement & Payment Authorization

At Heart Mind Body, we honor the therapeutic space as a protected investment in your healing. Financial agreements are part of creating a stable, respectful container where both client and clinician can fully engage in the work.

At Heart Mind Body (HMB), we are committed to providing high-quality, trauma-informed care with clarity, transparency, and respect for both your time and ours. This agreement outlines your financial responsibilities and our billing practices.

1. Payment Responsibility

You are responsible for all fees associated with your care, whether services are covered by insurance or provided on a self-pay basis.

Payment is due at the time of service, unless otherwise arranged in advance.

You agree to maintain a valid payment method on file at all times.

2. Insurance (If Applicable)

If you are using insurance:

• HMB may utilize third-party billing platforms (e.g., Headway) to process claims
• Your copayment, coinsurance, and deductible are determined by your insurance plan and are your responsibility
• Verification of benefits is not a guarantee of coverage
• You are responsible for any denied or unpaid claims

If your insurance does not pay for any reason, you agree to pay the full session fee.

3. Self-Pay Rates

For clients not using insurance, or for services not covered:

• Initial Evaluation: $500.00
• Follow-Up Session Medication Management: $250.00
• Extended/Specialty Services, Talk therapy regular scheduled: $250.00/55 minutes
• Crisis visit: Additional fee of $100.00 to regular fees listed above.
• Neurofeedback $135.00/session or a packet of 10 prepaid at $100.00/session, $1000.00.
• Ketamine medication varies based on compounding pharmacy costs/month; The 2 hour session is $300.00/session.

Payment will be charged to the card on file at the time of service unless otherwise arranged.

4. Missed Appointment & Late Cancellation Policy

Your appointment time is reserved exclusively for you.

A minimum of 48 hours’ notice is required to cancel or reschedule an appointment.

If you provide less than 48 hours’ notice, or do not attend your scheduled session, you will be charged a Missed Appointment Fee of $ 200.00.

• This fee is not billable to insurance
• This fee will be charged to your card on file or directly by Headway.
• Exceptions may be made at HMB’s discretion for emergencies, illness, or extenuating circumstances.
• Canceling more than 3 sessions per year, may result in termination of therapeutic relationship.

5. Credit Card Authorization (Required)

To support consistent care and reduce administrative burden, HMB requires a valid card on file.

Cardholder Information

Cardholder Name (as it appears on card): ______________________________________

Billing Address: _____________________________________________________________

City: __________________________ State: __________ Zip Code: ________________

Phone Number: _____________________________________________________________

Card Details

Card Type (circle one): Visa / MasterCard / American Express / Discover

Card Number: ______________________________________________________________

Expiration Date (MM/YY): __________ / __________

CVV (Security Code): ______________

Authorization Agreement

By signing below, you authorize Heart Mind Body, LLC to securely store and charge your card for:

• session fees not paid at time of service
• copayments, coinsurance, deductibles, and self-pay balances
• missed appointment or late cancellation fees
• returned payment or declined card fees

You acknowledge and agree that:

• Your payment information will be stored using a secure, HIPAA-compliant and PCI-compliant system
• Charges will only be applied in accordance with this agreement
• You are responsible for maintaining a valid card on file
• You may request receipts at any time
• You may revoke this authorization in writing (does not apply to prior charges incurred)

6. Returned Payments & Declined Cards

If a payment is declined or a check is returned:

• A fee of $45.00 will be applied
• You are responsible for updating your payment method promptly
• Future services may be paused until the balance is resolved

7. Outstanding Balances

Accounts with unpaid balances may result in:

• temporary pause in scheduling future appointments
• requirement of prepayment for future services
• referral to a third-party collections agency (as a last resort)

You will be notified prior to any such action.

8. Good Faith Estimate (Self-Pay Clients)

In accordance with the No Surprises Act, self-pay clients have the right to receive a Good Faith Estimate of expected charges upon request.

9. Communication & Administrative Fees (Optional – Customize if Desired)

HMB may charge for extended administrative services, including but not limited to:

• form completion
• letters or documentation
• extended phone consultations outside of scheduled sessions

You will be informed in advance if such fees apply.

10. Agreement & Acknowledgment

By signing below, you acknowledge that:

• You have read and understand this Financial Agreement
• You accept responsibility for payment of services rendered
• You agree to the missed appointment and payment policies
• You authorize HMB to charge your card on file as outlined above

Client Information & Signature

Client Name: ______________________________________

Date of Birth: _____________________________________

Cardholder Name (if different): _______________________

Signature: _________________________________________

Date: _____________________________________________