Adult OCD Treatment Group Intake Form

What can I expect from the Adult OCD Treatment Group?

The Adult OCD Treatment Group at Light On Anxiety will provide you with an opportunity to connect with others and participate in action-oriented, hands-on exposures to help you move through and past your OCD symptoms. We strive to maintain an environment where each group participant will feel respected and valued while working towards their individual goals.

Confidentiality

You have the expectation of privacy in group sessions. The information you share is confidential and will not be disclosed by the Light On Anxiety therapist without your written permission unless required under Illinois and Federal law. Disclosure is required by law if you may pose a danger to yourself or others.

All members of the group are expected to maintain a high level of confidentiality in group sessions. This means each participant agrees not to share any other group member's identifying and personal information with others. Conversations and stories shared within the group are not to be discussed with anyone outside of the group.

Insurance-Based Services

Light On Anxiety is an in-network provider with Blue Cross Blue Shield of Illinois (BCBSIL) Preferred Provider Organization (PPO), Blue Choice PPO and Aetna. Your insurance will provide a quote of benefits, not a guarantee of payment. While the filing of insurance claims is a courtesy we extend to our in-network clients, all charges are your responsibility from the date services are rendered. If your insurance company has not paid a claim within twenty (20) days of submission, you accept full responsibility for payment in full for any outstanding balance.

It is recommended that you contact your insurance company prior to beginning treatment at Light On Anxiety in order to review your specific benefits including preauthorization requirements and your copay and deductible amounts.

For all other insurance plans, clients are responsible for paying Light On Anxiety directly. We are happy to submit claims electronically, on a monthly basis, to facilitate obtaining out of network payment. We recommend contacting your insurance company to learn about your out of network benefits.

Private Pay Rates

All clients not utilizing in-network insurance have the right to receive a "Good Faith Estimate". The private pay rate for Group Therapy is $60 per session or $300 for a package of 6 sessions (paid upfront).

Cancellation Policy

All appointments cancelled with less than 24 hours notice are subject to a cancellation fee. Charges for missed appointments are not covered by insurance and are your responsibility.

Coordination of Care

Light On Anxiety values collaborative care with other providers as it helps to create the most integrated and appropriate treatment plan. If you are currently taking psychotropic medications, Light On Anxiety requires a 20 minute collaborative care meeting with the medication prescriber at the start of treatment.

If you are using insurance benefits for Light On Anxiety services, we will attempt to obtain reimbursement for this collaborative care service from your insurance company. If the insurance company does not provide reimbursement, you will be charged at a prorated private pay rate. We attempt to keep all collaborative care exchanges as quick and effective as possible, typically about 20 minutes.

Collaborative care will be billed at a prorated rate based on the time spent. Twenty (20) minutes of collaborative care will be billed at a rate of $70.

1. There is a 24 hour cancellation policy. When I schedule an appointment and cannot attend a session, I must provide at least 24 hours notice. If I do not provide at least 24 hours notice, I will be charged a $40 cancellation fee. I understand that this cancellation fee will not be covered by insurance.

2. Payment of services (copays and deductibles) is expected at the time of service. If in-network health insurance is used for my sessions, Light On Anxiety will seek reimbursement from the health insurance company. Any unpaid amounts, copayments and deductibles are my responsibility to pay.

3. I authorize recurring charges for fees, copayments and deductibles to be charged to the credit card provided on this form.

I authorize the payment of fees to Light On Anxiety for services rendered. I authorize that my card may be used to resolve any and all balances in full for session charges, consultative charges and cancellation fees. I agree to provide payment at the time services are rendered. I agree to maintaining up to date credit card information on file to resolve all balances for services provided, unless otherwise agreed in writing with Light On Anxiety. I understand and acknowledge that late payments may be subject to an additional late payment fee and that ongoing noncompliance with payment terms may incur collection charges if the outstanding balance is not resolved in a timely manner.