My standard fee is $120 per clinical hour (53 mins). Group therapy rates are generally lower, and vary per type of group.

Although I am unable to take insurance, I am able to provide a “super bill” for your use in seeking reimbursement from your insurer. If you are seeking reimbursement from your insurer, I cannot guarantee that services will be covered, but I am able to walk this process with you.

Just so you know, the insurance process can be difficult to navigate and I recommend that you contact your insurance provider to verify how your plan compensates you for psychotherapy services. Ask these questions to help provide clarity regarding your coverage:

• Does my health insurance plan include mental health benefits?

• Is my provider in-network with my insurance?

• If not, are out-of-network behavioral health services reimbursable under my insurance plan? At what rate? What is the process for making this claim?

• Do I have a deductible? If so, what is it and have I met it yet? Do I have co-insurance? What are my maximum annual out-of-pocket expenses?

• Does my plan limit how many sessions per calendar year I can have? If so, what is the limit?

• When does my insurance calendar year reset?

• Do I need written approval from my primary care physician in order for services to be covered?

Session fees may be paid using cash, checks, and all major credit cards. Payment will be arranged directly through my electronic health record system when you complete your intake paperwork.

If you need to cancel or reschedule a session, it is required that you provide more than 24 hours’ notice. If you cancel within the 24-hour window, you will be charged $60 which is 50% of the session fee. If you miss a session without canceling and there is a no-call-no-show you must pay the full fee ($120) for the missed session. You are responsible for coming to your session on time and at the time scheduled. If you are late, your appointment will still need to end on time and you will be billed for the entire session.

(OMB Control Number: 0938-1401)

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care - like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensive services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you unless you give written consent and give up your protections.

You’re never required to give up your protection from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following protections:

You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

Your health plan generally must: Cover emergency services without requiring you to get approval for services in advance (prior authorization), cover emergency services by out-of-network providers, base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits, and count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, please contact: Jessa Dillow Crisp at 720-383-4645. Or, you may contact the Colorado Division of Insurance at (303) 894-7490 or 1-800-930-3745.

Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdffor more information about your rights under Federal law.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

A law known as HIPAA requires this notice. In the course of doing business, Jessa Dillow Crisp gathers and maintains personal information about you. Jessa respects the privacy of your Protected Health Information as required by law. This notice describes privacy practices and how she protects the confidentiality of your PHI

Protected Health Information (PHI): PHI is information that identifies who you are and relates to your past, present, or future physical or mental health condition, the provision of health care to you, or a past, present, or future payment for provision of health care to you.

Please note that I reserve the right to change the terms of this Notice and my privacy policies at any time. Any changes will apply to PHI already on file with me. Before I make any important changes to my policies, I will immediately change this Notice and post a new copy of it in my office. You may also request a copy of this Notice from me, or you can view a copy of it in my office.

How we protect your PHI: Access to your PHI is limited to those employees who have a need to use the information for billing, administrative or similar purposes, or who become involved with an issue regarding your health or a claim on your behalf. We maintain appropriate physical, electronic, and procedural safeguards to protect your PHI against unauthorized use or disclosure.

Types of uses and disclosures of PHI we may make without your authorization:

Treatment - We may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are otherwise involved in your care. Example: If a psychiatrist is treating you, we may disclose your PHI to her/him in order to coordinate your care.

Payment – We may use and disclose your PHI to bill and collect payment for the treatment and services we have provided you. Example: We might send your PHI to your insurance company or health plan in order to get payment for the health care services that we have provided to you. We could also provide your PHI to business associated, such as billing companies, claims processing companies and others that process health care claims for my office.

Health Care Operations - We may disclose your PHI to facilitate the efficient and correct operation of our practice. Examples: Quality control – We might use your PHI in the evaluation of the quality of health care services that you have received or to evaluate the performance of the health care professionals who provided you with these services. We may also provide your PHI to my attorneys, accountants, consultants, and others to make sure that we am in compliance with applicable laws.

Jessa Dillow Crisp is also allowed to use and disclose your PHI without your consent or authorization for the following purposes:

• When disclosure is required by federal, state, or local law; judicial, board, or administrative proceedings; or, law enforcement.

• If disclosure is compelled by a party to a proceeding before a court pursuant to its lawful authority.

• If disclosure is required by a search warrant lawful issued to a governmental law enforcement agency.

• If disclosure is compelled by the client or the client’s representative pursuant to state or federal statutes or regulations, such as the Privacy Rule that requires this Notice.

• To avoid harm. We may provide PHI to law enforcement personnel or persons able to prevent or mitigate a serious threat to the health or safety of a person or the public.

• If disclosure is compelled or permitted by the fact that you are in such mental or emotional condition as to be dangerous to yourself or the person or property of others, and if I determine that disclosure is necessary to prevent the threatened danger.

• If disclosure is mandated by the Colorado law.

• If disclosure is mandated by the Colorado Elder/Dependent Adult Abuse Reporting law.

• If disclosure is compelled or permitted by the fact that you tell me of a serious/imminent threat of physical violence by you against a reasonably identifiable victim or victims.

• For public health activities. Example: In the event of your death, if a disclosure is permitted or compelled, we may need to give the county coroner information about you.

• For health oversight activities.

• For specific government functions.

• For research purposes. In certain circumstances, I may provide PHI in order to conduct medical research.

• For Workers’ Compensation purposes. I may provide PHI in order to comply with Workers’ Compensation laws.

• Appointment reminders and health related benefits or services. Examples: we may use PHI to provide appointment reminders. We may use PHI to give you information about alternative treatment options, or other health care services or benefits we offer.

If an arbitrator or arbitration panel compels disclosure, when arbitration is lawfully requested by either party, pursuant to subpoena duces tectum (e.g., a subpoena for mental health records) or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel.

I am permitted to contact you, without your prior authorization, to provide appointment reminders or information about alternative or other health-related benefits and services that may be of interest to you.

If disclosure is required or permitted to a health oversight agency for oversight activities authorized by law.

If disclosure is otherwise specifically required by law.

Authorizations:

All other uses and disclosures of your PHI will be made by Jessa Dillow Crisp only with your written authorization. You may revoke your authorization at any time in writing.

Your rights concerning your PHI:

Access to your personal information – As a matter of federal and state law, you have the right to review and copy your PHI that is in our possession. If you desire access to your PHI, you must notify Jessa Dillow Crisp in writing. She will respond to your request within 30 days. If you request a copy of your PHI, a copy may be provided. A reasonable fee for copying will be charged. However, under federal law, you may not inspect psychotherapy notes or information compiled in reasonable anticipation of, or use in, a civil, criminal, or administration proceeding.

Right to request restrictions – You have the right to request a restriction on how we use and disclose your PHI. All requests must be made in writing. Upon receipt, we will review your request and notify you whether we have accepted or denied your request. Please note that we are not required to grant your request. If we do agree to your request, we put those restrictions in writing and abide by them except in emergency situations.

Right to amend your PHI – If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that I correct the existing information or add the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of our receipt of your request. We may deny your request, in writing, if we find that: the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of our records, or (d) written by someone other than LRG personnel. Our denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and my denial be attached to any future disclosures of your PHI. If we approve your request, we will make the change(s) to your PHI. Additionally, we will inform you that the changes have been made, and we will advise all others who need to know about the change(s) to your PHI.

Right to request confidential communications – You have the right to request that we communicate with you about your PHI matters in a certain and at a certain location. Example: You may request that we communicate with you by sealed envelope rather than post card or calling you at work.

Right to get a list of disclosures – You are entitled to a list of disclosures of your PHI that we have made. The list will not include uses or disclosures to which you have already consented, i.e., those for treatment, payment, or health care operations, sent directly to you, or to your family. Neither will the list include disclosures made for national security purposes, to corrections or law enforcement personnel, or disclosures made before April 15, 2003. After April 15, 2003, disclosure records will be held for six years.

Right to Complain:

You will not be penalized for filing a complaint. If you believe your privacy rights have been violated, you may file a complaint in writing to:

Jessa Dillow Crisp, 1250 S. Buckley Rd. Unit I-234, Aurora, CO 80017

You may also notify the Secretary of the Department of Health and Human Services.

The effective date of this Notice is March 13, 2022