Effective Date: January 1st, 2026

1. Payment and Billing Policy

I acknowledge and understand that I am financially responsible for all charges associated with services rendered to me or to any individual for whom I am listed as the responsible party. While Mindful Oasis, LLC may verify insurance benefits as a courtesy before appointments, I understand that it is my responsibility to confirm my specific health plan coverage, including copayments, deductibles, pre-authorizations, and service exclusions. I also agree to review Explanation of Benefits (EOB) statements to stay informed of my financial obligations. Final responsibility for payment lies with me.

I agree to pay all costs not covered by insurance, including deductibles, coinsurance, copayments, or self-pay fees as applicable.
I UNDERSTAND THAT IF I DO NOT PROVIDE MY INSURANCE INFORMATION AT LEAST 48 HOURS PRIOR TO MY INITIAL OR FOLLOW-UP VISIT, I WILL BE CHARGED THE SELF-PAY RATE. If, for any reason, there is a balance due on my account, I agree to pay promptly upon receipt of the statement.
If valid insurance information is submitted later and coverage is confirmed, a retroactive claim may be filed. Any resulting overpayment will be refunded.
By placing a credit card on file, I authorize Mindful Oasis, LLC to charge my card for:

• Appointment fees
• Late cancellation or no-show charges
• Outstanding balances

• This authorization may be revoked at any time in writing. Charges will not apply in cases where federal or state law prohibits such billing, including for patients enrolled in Medicaid or similar programs.
• If Mindful Oasis is an in-network provider for my insurance, we will collect only the estimated patient responsibility. Unless written proof from the insurer is presented confirming that the deductible has been met, any deductible amount will be collected at the time of service. If my insurance later covers the visit, I will receive a reimbursement.
• In the event of a balance due, I agree to pay promptly upon receipt of a billing statement. If my account becomes overdue and no payment plan has been arranged, Mindful Oasis, LLC reserves the right to pursue appropriate measures to collect payment. This may include utilizing a third-party collection agency, legal process, or other means as necessary. Only the minimum necessary information will be disclosed in compliance with HIPAA. I understand that any additional costs associated with these efforts will be my responsibility. In the event of collection activity, I further understand that reasonable third-party fees may be added to the balance, as permitted by law.
• We accept exact cash, Visa, Mastercard, and Discover payments. Personal checks are not accepted.
• If payment is not made within 30 days and no payment arrangements have been agreed upon, no further appointments can be scheduled. Patients must either bring their account balance to $0 or pay at least half of the outstanding balance prior to scheduling any additional appointments. Additionally, no services, including medication refills, therapy services, or any other services, will be rendered until all balances are paid in full or a payment agreement approved by the Office Manager is in place.
• If I experience financial hardship, I am encouraged to notify Mindful Oasis, LLC. Accommodations or alternative payment options may be considered on a case-by-case basis.
• If there are any changes to my insurance coverage, mailing address, phone number, or other demographic details, I agree to inform Mindful Oasis at check-in or as soon as possible.
• If I use insurance for billing, I authorize Mindful Oasis, LLC and its billing agents to file claims on my behalf and to release any required information—including diagnosis codes and dates of service—to my insurance carrier in compliance with HIPAA. I also authorize insurance payments to be made directly to Mindful Oasis, LLC.
• Although Mindful Oasis, LLC may assist in billing, I understand that it is my responsibility to ensure my account is paid in a timely manner. If my insurance company fails to pay for any portion of the charges, I agree to promptly pay the remaining balance. I clearly understand that professional services are rendered and charged to the client, not the insurance company. Even if I request Mindful Oasis, LLC to bill my insurance company on my behalf, it is still my responsibility to make sure the bill is paid in a reasonable time.

 

2. Payments & Insurance Reimbursement

Clients are expected to pay for services at the time they are rendered unless prior arrangements have been made in writing. Payment for standard fees is due at the end of each session or at the end of the month, unless other arrangements have been made. The following are the standard fees for services provided at Mindful Oasis, LLC:

Self-Pay Fees (Effective January 1, 2026)

Initial Psychiatric Evaluation

• Psychiatric diagnostic evaluation: $255
• Psychiatric diagnostic evaluation with medical services: $275

Medication Management

• Medication management follow-up: $155 flat fee

Medication Management with Psychotherapy Add-On (Same Session fee for medication mngt plus below)

• Psychotherapy add-on, approximately 15–20 minutes: $55
• Psychotherapy add-on, approximately 30-45 minutes: $75
• Psychotherapy add-on, approximately 45-60 minutes: $100

Psychotherapy (No Medication Management)

• Individual psychotherapy, 30 minutes: $125
• Individual psychotherapy, 45 minutes: $165
• Individual psychotherapy, 60 minutes: $185

Family Therapy

• Family therapy with/ or without patient present: $185

• Document Preparation: $80 base fee + $80 per additional 15 minutes
• Consultation with Third Party (20 minutes): $175
• Medical Testimony (including travel): $400 per hour

 

• Additional services such as telephone consultations, chart reviews, report preparation, interprofessional collaboration, extended sessions, or travel time will be billed at the same rate as the applicable visit unless otherwise agreed upon in advance.
• Fees may be updated periodically. Updated fees apply to services scheduled on or after the effective date and will be communicated in writing and/or posted on the Mindful Oasis website.
• Clients must notify Mindful Oasis, LLC promptly if there are any concerns regarding their ability to make timely payments. We are committed to working with clients when possible, and payment plans or hardship accommodations may be available upon request and approval.
• Clients who carry insurance should remember that professional services are rendered and charged to the clients, not to the insurance companies. While Mindful Oasis, LLC may submit claims on your behalf, you are ultimately responsible for full payment of any balances not paid by insurance.
• Unless agreed upon otherwise, a monthly statement or receipt will be provided upon request. Clients may use these documents to seek reimbursement from their insurance plan if desired.

 

Important Note on Reimbursement Risks:
As explained in the Health Insurance & Confidentiality of Records section, submitting documentation to insurance may involve the release of mental health diagnoses, session dates, and clinical information. Some mental health diagnoses or services may not be reimbursed by insurance providers.

It is the client’s responsibility to verify their specific mental health benefits, including whether services like psychotherapy, medication management, or telehealth are covered.

 

If a client’s account becomes overdue and no written payment plan exists, Mindful Oasis, LLC reserves the right to pursue payment through appropriate means, including the use of third-party collection agencies or legal action. As with other collection activity, only the minimum necessary information will be disclosed, in accordance with HIPAA.

 

3. Grandfathered Fee Policy

Certain established patients may qualify for grandfathered self-pay rates based on prior fee schedules. Eligibility is determined at the discretion of Mindful Oasis, LLC and applies only to specific services as documented in the patient’s account.

Grandfathered rates:

• Apply only while the patient remains active in care
• May be discontinued if there is a lapse in care exceeding 90 days
• May be revoked if account balances become overdue or attendance policies are violated

Grandfathered rates are not transferable and may be modified or discontinued with written notice.

Grandfathered rates are not calculated using the sliding scale percentages or hardship fee structure. They are based on specific provider-approved arrangements in place before December 1, 2025, and are documented in the patient’s account accordingly.

4. Insurance

If you have health insurance, it may offer some coverage for mental health services. However, coverage varies by plan, and many services require prior authorization.
It is the client’s responsibility to confirm all mental health coverage details with your insurance company before your visit. This includes:

• Whether Mindful Oasis, LLC is in-network or out-of-network
• Whether preauthorization is required
• Whether telehealth or specific services are covered
• Your copay, coinsurance, and deductible obligations
• Any limitations on the number of sessions

Some insurance plans require providers to share clinical information—including diagnoses, session dates, treatment type, and progress updates—with the insurer to determine eligibility or reimbursement. Most insurance companies require authorization for a clinical diagnosis, and your provider may need to provide additional clinical information that becomes part of the insurance company’s records. By signing this agreement, you consent to the release of such information to your insurance carrier for the purpose of claims processing, as allowed under HIPAA.

Important:

The diagnosis given to your insurance company may become part of your permanent insurance record and could affect future coverage or premiums.

 

Preauthorization may be required for certain services such as:

• Initial psychiatric evaluations
• Ongoing therapy
• Medication management
• Telehealth sessions

While we may try to obtain authorization as a courtesy, it is ultimately the patient’s responsibility to fully understand their insurance policy, obtain any necessary authorizations, and ensure their visit is covered before the appointment.

Although Mindful Oasis, LLC may assist in obtaining preauthorization or checking benefits as a courtesy, this does not guarantee approval or coverage.

 

Mindful Oasis, LLC may verify benefits as a courtesy, but this does not guarantee coverage or payment. Patients are responsible for understanding their own benefits and for all charges not covered by insurance.

If your insurance coverage changes at any time, you must inform Mindful Oasis immediately.
If you fail to notify us of a lapse in insurance or coverage change before your visit, you will be responsible for the self-pay rate at the time of the appointment.

 

Many insurance plans require you to pay a portion of the visit fee, such as a copay, coinsurance, or deductible, at the time of service. These amounts will be collected in advance according to your plan’s estimate.

 

If your plan includes a deductible that has not yet been met, you are responsible for the full contracted rate, which are out-of-pocket amounts that patients must pay until your deductible is satisfied. Proof of deductible satisfaction must be presented in writing from your insurance company.

 

Secondary Insurance (Out-of-Network)

If you have secondary insurance and Mindful Oasis, LLC is not in-network with that plan, we will not bill the secondary insurance on your behalf.
You are responsible for any portion of the bill not paid by your primary insurance. Upon request, we will provide a superbill or itemized statement to help you seek reimbursement from your secondary plan.

We recommend contacting your secondary insurance carrier directly to:

• Confirm if they reimburse out-of-network mental health services
• Understand how to submit a claim yourself
• Learn what documentation is required

Any unpaid balance not covered by your insurance(s) remains your responsibility.

 

Changes in Coverage

If your insurance coverage changes or there is a lapse in your plan, you must inform us before your next appointment.
Failure to notify our office will result in you being billed at the self-pay rate, due at the time of service. You may still submit claims to your insurance afterward if eligible.

 

5. Scheduling, Cancellations & No-Show Policy

New Patients:

• All new patients are required to complete all new patient paperwork within 7 days of receiving it.
• If paperwork is not completed within the first 7 days, patients will be granted an additional 7-day grace period to complete it.
• If paperwork is not completed within 14 days total, the paperwork will expire, the request for an appointment will be canceled, and the patient will be marked as inactive. Patients who become inactive must submit a new request to restart the scheduling process.
• New patients Appointments will not be scheduled until all required paperwork, consents, and documents are submitted in full.
• If you choose not to sign the required intake forms, Mindful Oasis cannot proceed with treatment. You will be referred to appropriate external providers.

Established Patients

 All established patients must maintain a valid credit or debit card on file at all times.

Payment & Authorization Requirements

• All patients of Mindful Oasis, LLC are required to maintain a valid and active credit card on file at all times. Patients must use the link provided to create a patient portal account and add a credit card on file under the Billing & Payments section prior to being seen.
• All visits require payment collection on the day of the scheduled appointment, including copays, deductibles, and self-pay fees.
• These amounts will be charged automatically to the credit card on file on the day services are rendered.
• Payment must be completed before or immediately following the start of the appointment.
• If an outstanding balance remains and no approved payment plan is in place, no additional appointments, medication refills, therapy sessions, or other services will be provided until the balance is resolved.
• If an attempt to collect payment fails, the office will make reasonable efforts to contact you; however, it remains your responsibility to ensure your payment method is valid. If payment is not successfully collected on the day of your appointment, your appointment may be canceled or future appointments may be withheld until payment is resolved.
• If an appointment is canceled due to provider unavailability or office closure after payment has been collected on the day of service, a credit will be applied to your account for a future appointment. If the credit is not used within thirty (30) days, it will be refunded to the card on file. Refunds will only be issued to the card on file; no cash refunds will be provided.

Cancellations & No-Shows

• If you are unable to attend your appointment, you must cancel at least twenty-four (24) hours in advance (weekends excluded) to avoid a $120 late cancellation or no-show fee.
  For Monday appointments, cancellations must be submitted by the same hour on the preceding Friday.
  A no-show is defined as:
  • Missing an appointment without notifying the office.
  • Canceling with less than twenty-four (24) hours’ notice.
  • Arriving more than ten (10) minutes late for in-person visits or more than five (5) minutes late for virtual visits without being accommodated at the provider’s discretion.
• The $120 late cancellation/no-show fee is not billable to insurance and will be the patient’s financial responsibility.
• Mindful Oasis, LLC understands that emergencies and unforeseen circumstances may occur. At its discretion, the cancellation or no-show fee may be waived for documented hardship or qualifying emergencies. Each patient is eligible for one (1) waived cancellation or no-show fee per calendar year. Requests for fee waivers must be submitted in writing within five (5) business days of the missed appointment.
• Patients with three (3) or more no-shows or late cancellations may be discharged from the practice and
• referred to external providers for continued care.

Late Arrival Policy

• If you arrive late to your appointment—being more than ten (10) minutes late for in-person visits or more than five (5) minutes late for virtual visits—you may not be seen at your scheduled time.
• At the provider’s discretion, you may either:
  • Be added into a later opening that same day if the schedule allows, which may require an extended wait, or
  • Be marked as a no-show and charged the $120 late cancellation/no-show fee if accommodations cannot be made.
• Patients are responsible for arriving on time. If you arrive late and cannot be accommodated, the appointment will be treated as a no-show, and the late cancellation/no-show fee will apply.
• If you are seen despite a late arrival, the session may be shortened, and you will still be responsible for the full visit fee.
• Repeated late arrivals may be treated as non-compliance and grounds for discharge from the practice.

 

Medicaid Patients Only

• In accordance with Medicaid regulations, no-show and cancellation fees will not be charged to Medicaid beneficiaries.
• Consistent attendance is required to remain active in care.
• New Medicaid patients who miss their first appointment or cancel late may not be rescheduled.
• Established Medicaid patients may have up to two (2) same-day cancellations or no-shows per year (excluding emergencies). After this limit, dismissal from the practice may occur with written notice and referrals.

 

6. Valid Identification and Insurance Card Requirement

• I understand that I must present both a valid form of identification and my insurance card for my initial intake appointment, whether in person or via telehealth. Appointments will not be scheduled or confirmed until valid documentation is received.
• Identification and insurance documents must:
  • Be uploaded via the provided link along with my intake paperwork at least 24 hours in advance.
  • Be a hard copy (not a photo or digital copy) if presented at the appointment.
  • Be valid and active (not expired).
  • Display a clear and recent photo sufficient for identification.
• Failure to provide valid identification and insurance information at least 24 hours prior to the intake appointment will result in cancellation or rescheduling.
• Patients who repeatedly fail to provide required documentation may be discharged from the practice or referred to external providers.
• If intake paperwork and documentation are not completed within the required timeframe (14 days total), the request will be closed and the patient’s status marked as inactive until a new request is submitted.
• If I fail to complete the upload process as described or fail to provide valid ID and insurance information, my intake appointment will be rescheduled, and depending on appointment availability, it may take several weeks to reschedule.

 

7. Hardship & Good Faith Estimate Rights
   Patients who are uninsured, out-of-network, or self-pay have the right to request a Good Faith Estimate of expected charges for services, in accordance with the No Surprises Act. This estimate will outline the anticipated costs for scheduled services based on the information available at the time of the request. The Good Faith Estimate is not a contract and may change if additional or different services are provided during the course of care.

Patients experiencing financial hardship may apply for Mindful Oasis, LLC’s Financial Hardship & Sliding Scale Program. Approved hardship discounts are applied using a three-tier system based on income and household size, in alignment with federal poverty guidelines. The tiers apply only to approved services under our hardship program and are calculated as follows:

• Tier A: 60% of the hardship base rate
• Tier B: 40% of the hardship base rate
• Tier C: 20% of the hardship base rate

These tiers are not based on standard self-pay fees or insurance rates, but on the internally set hardship base fees as approved by Mindful Oasis. Tiers are assigned upon application approval and documented in the patient record.

Participation in this program is not automatic and requires completion of a separate application along with submission of supporting documentation, which may include but is not limited to recent tax returns, pay stubs, benefit award letters, or other proof of financial need. Eligibility determinations are made at the sole discretion of Mindful Oasis, LLC.

Approved hardship or sliding scale participation applies only to eligible self-pay services and does not apply to insurance copayments, deductibles, coinsurance, missed appointment fees, late cancellation fees, or other non-covered charges, unless expressly permitted by the patient’s insurance plan.

Financial hardship approvals are time-limited and subject to periodic review and re-certification. Patients must comply with all program requirements, including attendance policies, timely payment of any reduced balances, and ongoing eligibility verification. Mindful Oasis, LLC reserves the right to modify, suspend, or discontinue hardship accommodations if documentation is incomplete, outdated, inaccurate, or if program requirements are not met.

Patients approved for financial hardship accommodations are required to promptly notify Mindful Oasis, LLC of any changes in financial circumstances, employment status, or insurance coverage. Failure to disclose changes or providing inaccurate information may result in immediate termination from the program and reinstatement of standard fees.

If a patient does not apply for, does not qualify for, or is removed from the Financial Hardship & Sliding Scale Program, standard fees and payment policies will apply.