Clinic Patient Terms and Financial Policy

Effective Date: [Effective Date]

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Mindbloom Medical Group of TX PLLC
Mindbloom House Austin, 3906 Menchaca Rd, Austin, Texas 78704

1. Who provides your care

Your care at Mindbloom House Austin is provided by Mindbloom Medical Group of TX PLLC (the “Practice”), an independently owned and operated medical practice. Licensed clinicians at the Practice make all decisions about your care. Mindbloom, Inc. provides technology, administrative, billing, and support services to the Practice and does not provide medical care. Payments you make go to the Practice and will appear on your statement as “[Statement Descriptor].”

2. Services

The Practice offers transcranial magnetic stimulation (TMS), Spravato® (esketamine), psychiatric evaluation and medication management. Your clinician decides whether a service is right for you after an evaluation. Some services have specific eligibility, safety, or monitoring requirements, and you’ll be asked to sign separate consent forms for them.

3. Telehealth visits

Your first psychiatric consultation, and some follow-up visits, may take place by secure video. You must be physically located in Texas during each telehealth visit. Telehealth visits are billed to your health plan and paid the same way as in-person visits.

4. Insurance

(a) We bill your health plan for covered services if the Practice is in network with your plan. If we are not in network with your plan, we will tell you before your visit. With your agreement, we will submit claims to your plan, but you may owe more than you would in network.

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(b) Before your first visit, and again when your coverage or treatment changes, we’ll check your benefits and request prior authorization where your plan requires it. A benefits check is an estimate, not a guarantee of payment. Your plan makes the final decision.

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(d) If you have Medicare, Medicaid, or another government program, different payment rules may apply. We will explain them before your first visit.

5. Assignment of benefits

You assign to the Practice your right to receive payment from your health plan for services the Practice provides to you, and you authorize your plan to pay the Practice directly.

6. Sharing information with your plan

You authorize the Practice to share with your health plan, and with anyone acting for it, the information needed to obtain payment. This includes diagnosis, treatment, and records requested to support a claim, prior authorization, or appeal. Texas law does not allow you to revoke consent to disclosures required to obtain payment for services already provided.

7. Your financial responsibility

(a) You’re responsible for:

copays, deductibles, and coinsurance under your plan
services your plan does not cover, if we told you before the service that it may not be covered
charges for any service you choose to pay for yourself

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(b) You are not responsible for:

amounts your plan denies because the Practice failed to obtain a required prior authorization or to file a claim on time
amounts above your plan’s allowed amount for in-network services, except as your plan allows

8. Estimates

(a) If you use insurance, we’ll estimate your share of the cost for each visit based on your benefits. We’ll show you the estimate when you book or before the visit, and update it if your benefits or treatment plan change.

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(b) If you don’t have insurance, or choose not to use it, you’ll pay our self-pay rates. You have the right to receive a Good Faith Estimate of expected charges. We provide it within 1 business day after scheduling when your visit is 3 to 9 business days away, and within 3 business days after scheduling or your request in other cases. See Right to a Good Faith Estimate notice.

9. Payment card on file

We ask you to keep a payment card on file. When you add your card, you will be shown a separate authorization and asked to agree to it. Under that authorization, the Practice may charge your card for:

your estimated share of the cost, on the day of and before each visit
any remaining balance after your plan processes the claim, as described in Section 10
late cancellation and missed appointment fees, as described in Section 12
self-pay charges you have agreed to

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If you use a debit or HSA card, you may choose to receive written notice at least 10 days before each charge, or only when a charge is more than an amount you choose.

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You can update your card or cancel the authorization at any time by contacting [Billing Contact]. Cancelling does not cancel amounts you already owe, and we may ask for another payment method before your next visit. This authorization remains in effect until you cancel it or are no longer a patient of the Practice. We’ll send you a copy of your authorization by email.

10. Balances after your plan pays

After your plan processes a claim, we’ll send you an itemized bill if you owe more. The bill will include:

a plain-language description of each service
the billing codes we submitted
the amounts billed to and paid by your plan
the amount you owe

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We’ll send it within 30 days after your plan’s final payment and at least [7] days before we charge your card. You can ask for an itemized bill at any time.

11. Refunds

If you paid more than you owe, for example because your estimate was higher than your final share, we’ll refund the difference to your card on file within 30 days after we determine the overpayment. We’ll refund to your original payment method unless you ask us to apply it to a future visit.

12. Cancellations and missed appointments

(a) Please give at least [24] hours’ notice to cancel or reschedule. Spravato® sessions need [48] hours’ notice because they reserve a monitored treatment block of at least 2 hours.

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(b) Late cancellations and missed appointments are charged as follows. Health plans don’t pay these fees.

Psychiatric visits: $[__]
TMS sessions: $[__]
Spravato® sessions: $[__]

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(c) We’ll notify you before charging a fee. We may waive it for emergencies, illness, or other circumstances beyond your control.

13. Payment plans and hardship

If you’re having trouble paying a balance, contact [Billing Contact] before the charge date. We’ll work with you on payment options, which may include a payment plan.

14. Unpaid balances

If a charge to your card is declined, we’ll contact you to arrange another payment method. If a balance remains unpaid [90] days after we send your itemized bill, and we have tried to reach you, we may refer it to a collection agency. We will not pursue collection of any balance without first sending the itemized bill described in Section 10.

15. How we’ll contact you

By giving us your phone number and email, you agree that the Practice, and Mindbloom, Inc. acting on its behalf, may contact you by call, text, and email about your care. This includes scheduling, reminders, estimates, billing, insurance, and follow-up. Some messages may be automated. Message and data rates may apply. You can reply STOP to stop texts at any time, and we’ll reach you another way. Texts and regular email may not be encrypted. We’ll only send marketing messages if you separately agree.

16. Your privacy

Your health information is protected as described in the Practice’s Notice of Privacy Practices. Payment card records may show that you received services from the Practice.

17. Not for emergencies

The clinic does not provide emergency care. If you are in crisis or having a medical emergency, call 911 or go to the nearest emergency room. For a mental health crisis, call or text 988.

18. Questions and complaints

You can raise a billing or care concern with us at [Practice Phone] or [Practice Email]. You can also file a complaint with the Texas Medical Board; see the Notice Concerning Complaints.

19. Changes

We may update these terms. We’ll notify you at least [30] days before a material change applies to you. Changes apply only going forward and do not affect charges already incurred or disputes that have already arisen. Changes to your card authorization take effect only after we notify you.

20. Billing and payment disputes

Any dispute between you and the Practice about charges, estimates, billing, insurance payments, refunds, card-on-file charges, or collection will be resolved by binding individual arbitration under the “Disputes and arbitration” provision of the Mindbloom Terms of Use, which is incorporated here. That provision applies to these disputes despite its exclusion for clinic care. Either party may still bring an individual claim in small claims court. This Section also covers billing and payment disputes with the Practice’s service providers, including Mindbloom, Inc., acting on the Practice’s behalf. If the American Arbitration Association declines to administer a dispute, the parties will agree on another administrator, or a court will appoint one. This Section does not apply to any claim about the medical care you receive, which you may bring in court. Texas law governs these Terms, and the Federal Arbitration Act governs this Section.