Donny Baca, MA, LPC
I am the sole proprietor of DLB Counseling & Consulting, LLC. All consultants, independent contractors, interns or administrative personnel working for or on behalf of DLB Counseling & Consulting, LLC are required to maintain client confidentiality.
In the event of a life-threatening crisis or an if an emergency situation arises that requires immediate attention you should contact 911 or go to the nearest hospital emergency room. Additional resources available is the National Hopeline Network at 1-800-Suicide/1-800-784-2433 or National Suicide Prevention Lifeline at 1-800-Talk /1-800-273-8255 or dial 911. Hearing and Speech Impaired should call 1-800-799-4TTY/1-800-799-4889.
I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If, for any number of unseen reasons, you do not hear from me or I am unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, 1) go to your local Hospital Emergency Room, or 2) call 911. I will make every attempt to inform you in advance of planned absences and provide you with the name and phone number of the mental health professional covering my practice.
Payment for Professional Services Rendered
Cash, check, all major credit cards and Health Savings Account cards are accepted methods for payment. Co-Payment or self-pay payments is required at the beginning of each session. If your insurance company has authorized out-of-network care and you are going to submit a reimbursement request to your insurance company a service receipt will be provided to you once a month upon your request.
No-Show or Less Than 24 Hour Notice Cancellation
I understand that if I find it necessary to cancel my scheduled appointment, a 24-hour notice in advance is required to avoid charges. Sessions missed without a 24-hour cancellation will be charged $45.00 for the missed appointment. This fee must be paid prior to attending the next session. This charge cannot be submitted to your insurance company for payment. Failure to pay no-show fees could result in termination of services until paid. If your insurance program does not allow this office to charge for no shows/late cancellations, you will be allowed to rescheduled one (1) time and any subsequent no shows or late cancellations will be cause for termination of treatment. If you are late for a session it will be billed at the same rate as my scheduled 45-minute session. Cancellations MUST be made through your client portal account or by calling or texting Donny Baca at 719-459-9928.
Change of Fees
The fees established for services provided may be subject to change. In the event service fees are increased it will be posted on the business website under Rates, 60 days prior to the increase. If you are actively receiving counseling services you will be notified by Donny Baca, MA, LPC and your current rates will remain the same for an adjustment period of 60 days. If you are receiving Pro Bono or reduced counseling fees you may not be subject to the fee increase.
Record Review and Record Copying
You have the right to review and copy your clinical record and I will review your record with you. I will require up to 30 days for locating and producing a copy of the record. There will be a $35.00 fee associated with the production of your records (research & copies). You will be required to pay this fee upon request of your records. If your records request is made from an outside agency/source I will require a signed released of information form from you.
When served with a subpoena for my appearance in person or a disposition subpoena for my appearance, the following fee policies will be an effect. This is the case unless you receive a signed, written amendment from me. A $1,000.00 retainer will be required and will be due with the subpoena. My fee for a scheduled appearance is $250.00/hour paid in advance. There will be a $500.00 fee for my scheduling the day or any fraction of the day. The $500.00 fee is non-refundable and is due whether or not I am actually called on that day. The fee is due even if the appearance is canceled by anyone other than me for any reason and at any time. Most often, insurance companies will not reimburse for these services. It is the client’s responsibility to coordinate with their insurance company to determine if they are eligible for reimbursement for a court ordered appearance.
In the event there is a balance on your account you will receive a monthly bill from my office. No services will be provided if there is a balance due of more than $200.00. Payment is expected 15 days after receipt of a statement. If more than 90 days lapse without payment, unless arrangements have been made, I reserve the right to turn the account over for collection to my attorney or collections agency.
Paperwork or other requests will be a separate cost if not done during the allotted time ($75.00 per hour). Additionally, I acknowledge that my insurance will not reimburse me for my decision to see Donny Baca, MA, LPC privately and he is not to bill my insurance.
Behavioral Health Insurance
If I am not a participating provider for your insurance plan, I will supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers. Please be sure to discuss your insurance benefits with me so that you are aware of your out of pocket expenses. This should be done at the very beginning of your therapy.
In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. With your permission, my billing service and I will assist you to the extent possible in filing claims and ascertaining information about your coverage, but you are responsible for knowing your coverage and for letting me know if/when your coverage changes.
Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. Managed Health Care plans such as HMOs and PPOs often require advance authorization, without which they may refuse to provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.
You should be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. (Diagnoses are technical terms that describe the nature of your problems and whether they are short-term or long-term problems. All diagnoses come from a book entitled the Diagnostic and Statistical Manuel-5th Edition. There is a copy in my office and I will be glad to let you see it to learn more about your diagnosis, if applicable.). Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it.
In addition, if you plan to use your insurance, authorization from the insurance company may be required before they will cover therapy fees. If you did not obtain authorization and it is required, you may be responsible for full payment of the fee. Many policies leave a percentage of the fee (which is called co-insurance) or a flat dollar amount (referred to as a co-payment) to be covered by the patient. Either amount is to be paid at the time of the visit by check, cash or credit card. In addition, some insurance companies also have a deductible, which is an out-of-pocket amount that must be paid by the patient before the insurance companies are willing to begin paying any amount for services. This will typically mean that you will be responsible to pay for initial sessions with me until your deductible has been met; the deductible amount may also need to be met at the start of each calendar year. Once I have all of the information about your insurance coverage, I will discuss what I can reasonably expect to accomplish with the benefits that are available and what will happen if coverage ends before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above, unless prohibited by my provider contract.
Ethics and Professional Standards
As a therapist, I agree to abide by and uphold the most responsible ethical and professional standards possible. I will make every effort to protect the welfare of those who seek my services and to ensure that my services are used appropriately. If you are ever unhappy with my services or services provided by an independent contractor hired by me, it is especially important that you try your best to communicate with me the source of your dissatisfaction. Some clients do this in writing if they feel unable to do so verbally. If we should not reach an agreeable solution and you need help finding additional or alternative assistance, I will do my best to help you locate a more suitable referral of therapy services. Since therapists generally agree that it is not the patient’s best interests to be receiving similar services from another professional, should you wish to contract with another psychologist, psychiatrist or therapist for services, it is important that you indicate your desire to make a change and your basic reasons for doing so. There is also a complaint form you can request and fill out to report a problem. I take concerns or complaints very seriously and will respond immediately to all formal complaints.
If you need a referral to a psychiatrist, medication or hospitalization I can refer you to a number of different psychiatrists in the area, or if you already have a psychiatrist, I will be glad to work with whomever you need to be seen by. If you prefer to work with your family physician, I will also be willing to consult with him or her.
If, during the course of your therapy, you have any questions about the nature of your therapy (i.e. therapeutic goals, procedures, policies, fees) please ask me. This issue is even more important on matters which you fear might be embarrassing to either yourself or me. I strongly encourage you to bring such matters up for consideration since dealing with such matters is often an important part of your treatment.