Contact-Billing

September 15, 2023 |

Request Statement/Superbill

Reason For Communication

"*" indicates required fields

Name*

First Last

Email*

Phone*

Is it okay to text for scheduling?*

Yes

Location*

Duvall

North Bend

Any Location

Appointment Modality*

In-Person

Telehealth

Any Modality

Client Type/Program*

Referral Code*

In order to participate with this referral program, the counseling appointments must be relational in nature, meaning 2 or more family members, or a couple, must be present. With this agreement, the cost of therapy will be waived. The therapist that provide this service are our clinical interns who are working through their Masters program

How Did You Hear About Us?*

Hidden

End

Previous Counselor*

Fees & Insurance Policy - Please Read and Accept our Terms

Fees

Licensed and Associate Counselors: $165 (53 minutes)

Clinical Interns: $70 (53 minutes)

Payment is to be made at each session (we can save credit cards on your file to avoid dealing with payment each session).

Insurance

We are private pay providers, and are not In-Network or contract with any insurance companies. Although we understand that for some billing insurance is necessary, we believe there are many benefits to not billing insurance. For example, most insurance companies want to dictate how counseling is to be conducted, and what types of counseling will be covered, often denying certain types of couple and family work, and requiring a diagnosis for reimbursement. We believe that counseling is more effective if it is controlled by the counselor and client, rather than being dictated by a third party. Another benefit to not taking insurance is we can spend more time providing care to the people we work with, instead of spending hours completing all the paperwork and figure out the requirements of each insurance company.

**Out of Network Reimbursement

Sometimes insurance companies reimburse for Out of Network Providers for some types of services. Because of this, we are happy to submit these claims for you, but do not tailor our work towards insurance companies and reimbursement for the cost of counseling. We often recommend people seek treatment with us if reimbursement is not necessary to cover the cost of treatment.

If you would like us to try to submit Out of Network claims electronically on your behalf, you can check the box to submit for possible Out of Network reimbursement

I have read and agree to the above Fees & Insurance information.*

Would you like Larch to electronically submit for possible Out of Network Reimbursement*

Yes Please

No Thank You

Insurance Disclaimer

We cannot guarantee any insurance reimbursement, but we have compiled what we have noticed from claims we have submitted on our clients behalf. We do know some insurance companies that will not reimburse, and those who may reimburse based on past experience.

Excluded Insurance Companies

These insurance plans will not reimburse for out of network services from Larch

*Anthem Blue Cross Blue Shield

*Apple Care Plans

*Medicaid Plans

*Medicare Plans

*Molina Healthcare

*Solidarity Healthshare

*Tricare

Consent to Insurance Policy
I have read the above Insurance Disclaimer and the full insurance policy here

Select your Insurance Provider*

Blue Cross Blue Shield Prefix

Blue Cross Blue Shield is either processed as Regence or Premera. In order to more quickly identify if it will reimburse, please provide us with the 3 digit numerical prefix

Superbill Policy

You have selected a numerical prefix that we cannot electronically submit. When this happens, the subscriber (you) may submit with a paper form called a “Superbill”. This is a special document that is like a statement, but includes our practice information, counselor information, appointment dates, as well as the diagnosis you were seen for. All of this information is needed by insurance companies to provide out of network reimburse.

If you are using this approach, we produce the Superbill around the 10th of the month for the previous month. For example, on Dec 10th, we send you a Superbill for all of November appointments. Once you receive this document, you can mail it to your insurance company based on their process for subscribers submitting for possible out of network reimbursement. You will need to reach out to them directly to get information on where to send the documents.

After Reviewing the Superbill Policy, would you like us to produce Superbills for you to submit to your insurance provider?*

Yes Please

No Thank You

Choose a Counselor

(Click on name to view profile)

Any Available Counselor
Any Available Counselor

Dan Claussen
Dan Claussen
*Unique rate of $200 per session

Aubrey Lane
Aubrey Lane

Jessica Milian
Jessica Milian

Serena Robertson
Serena Robertson

Victoria Morgan
Victoria Morgan

Abbygail Parker
Abbygail Parker (Associate)

Alexandra Grissom
Alexandra Grissom (Associate)

Danielle Smith
Danielle Smith (Associate)

Elliott Duea
Elliott Duea (Associate)

Garret Patterson (Clinical Intern)
Garret Patterson (Associate)

Jordan Beck
Jordan Beck (Associate)

Madison Dell (Associate)
Madison Dell (Associate)

Mario R. Gaspar de Alba
Mario R. Gaspar de Alba (Associate)

Alexandria Packard (Clinical Intern)
Alexandria Packard (Clinical Intern)

Allison Hanigan (Clinical Intern)
Allison Hanigan (Clinical Intern)

Shannon Sherman (Clinical Intern)
Shannon Sherman (Clinical Intern)

Schedule*
As a starting point, please provide us with days and times that cold work for you. We often have more AM appointment times available, so if you can accommodate that, it would help us provide the evening appointments for students and families who have more typical works/school schedules.

Prioritize:*

My Selected Therapist(s)

My Schedule

Cost/Insurance

Message*

*Please make sure you have entered the correct referral code in order to submit this form.

Name*
First Last
Email*

Phone*
Client Name*
First Last
I confirm I have permission to contact on behalf of the named client*

How can we help?*
Purpose of Statement*
Please Note

The statement you selected cannot be used to apply for potential out of network reimbursement. It is only to be used for HSA reimbursement if you are drawing from that account and are using a personal credit card, you want it for your own records, or you are using it for tax purposes.

I confirm I am not submitting the requested document for insurance reimbursement*

Review Documents

Before submitting a request for documents to bill insurance by yourself for possible out of network reimbursement, please first review the following documents.

Out of Network Insurance Claim Process

https://larchcounseling.com/insurance.pdf

Submitting for Reimbursement with a Superbill

https://larchcounseling.com/superbill.pdf
I confirm I have read the above documents, and am interested in submitting for out of network reimbursement.*

I confirm I have contacted my insurance company, and they informed me they reimburse out of network services for the License type of my counselor.*

Message*

Name*
First Last
Email*

Phone*
Message*
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