Lizzie Crawford, MA., LMHC

581 Boylston Street, Suite 802C, Boston, MA 02116

617 800 9860 lc@lizziecrawford.com

OFFICE INFORMATION AND POLICIES

OFFICE HOURS

I am in the office on Mondays each week between 10am-7pm. I will work with you to schedule a mutually agreeable time.

SESSIONS

Sessions are 50 minutes long. In order to ensure that your time is respected and waiting time does not interrupt your schedule and mine, every effort is made to start and stop on time.

CONTACT

I am available through email; however, email is not a secure mode of communication and should not be used to communicate private information. My email is encrypted and abides by HIPAA regulations, but it is still best to relay private information by phone. I typically am able to respond quickly by email and this mode helps to reduce phone tag, but do try to call my phone if more urgent matters arise. I will respond at my earliest convenience.

If you need to speak with someone right away or if there is any emergency, please call 911 or go to your nearest emergency room.

PROFESSIONAL FEES

I am committed to providing you with the best care possible. In order to achieve these goals, I need your assistance and understanding of my payment policy. Payment is expected and appreciated at the time of your session. I accept all major credit cards, cash, and checks.

My fee for individual sessions is $100-$110. I do accept some insurance, and I will file those claims accordingly. While filing of insurance claims is a courtesy, all charges are your responsibility from the date services begins. If I am not an in-network provider for your specific plan, I may be able to assist you to contact your insurance company to learn about your mental health benefits. If applicable, I will provide you with a detailed invoice. You can submit this document to your insurance company for them to reimburse you directly. I am also able to submit claims on your behalf.

The agreed payment/co-pay for services is $___________.

CANCELLATIONS

There will be a charge for any appointments that are cancelled or not attended without 24-hours advance notice. This allows for time for filling appointment with another client. The charge for missed and late cancelled appointments is $45. Insurance does not cover missed appointments, so it will be your responsibility to pay this amount.

INSURANCE ASSIGNMENT

You should be aware that utilizing your insurance requires me to relay information relevant to the services that I provide to you in order to receive reimbursement. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files.

Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid going through insurance.

By signing this Agreement, I authorize any payment of medical benefits from my insurance to be paid to Elizabeth Crawford. I authorize Elizabeth Crawford to provide my insurance carrier the Private Health Information (PHI) necessary to allow for coverage of sessions.

My signature below confirms that I HAVE READ AND FULLY UNDERSTAND THE INFORMATION PROVIDED ABOVE.

Signature of Client	Date

Signature of Witness	Date