Forms & Fees

Billing insurance

If you would like for me to find out about your benefits and/or bill your insurance, the CMS/HCFA 1500 is required.  Please download the form and fill it out.  You can then either scan it and email it to me along with a copy of your insurance card, or bring it with you to your first visit.  Please note that, while I can submit claims electronically to any carrier, I am only in-network with BCBS NC PPO.  If you have insurance other than BCBS NC PPO you will likely need to meet an out of network deductible before insurance will pay anything.  This means that you will need to be prepared to pay the full fee until we figure out what your benefits are.

NC Notice Form

This form is the new version of the Notice of Psychologists‘ Policies and Practices to Protect the Privacy of Your Health Information. This notice is not something you sign or consent to, rather it is information provided to you about what the law says about how psychological and medical information about you may be used and disclosed and how you can get access to this information. 

Out of Network Patient Contract

This is the contract for psychotherapy.  Please read it carefully as it spells out the contract that defines our doctor-patient relationship. My full fee for an initial evaluation is $309; subsequent visits are $220.

BCBS NC PPO Outpatient Contract

This is the contract for psychotherapy to use if you have insurance through BCBS NC PPO.  Please read it carefully as it spells out the contract that defines our doctor-patient relationship.  Depending on the specifics of your coverage, you will likely only need to pay your in-network office visit copay when you see me.  

Release of Confidential Information

Quality medical care in integrated care–care where your physical and mental and emotional challenges are considered together.  If you are referred by a physician, it is very helpful for me to be able to communicate directly with him or her about your care, but in order to do so, I will need to have your written consent. 

Now that all your paperwork is done, click here to schedule an appointment!