Skip Navigation
Skip Main Content

Fee Scheduling and Billing Policies

Copayments, Coinsurance, & Deductibles Policy


Copayments, Coinsurance, & Deductibles Policy

Your insurance plan likely requires you to cover a portion of the cost of your visit in the form copayments, coinsurance, and/or deductibles. If we are unable to determine an exact figure for your out-of-pocket responsibility at the time of visit, we will charge you approx. 90% of what we believe you owe, and collect the remainder once we bill your insurance and have an exact amount.

  • Example: If you owe 30% coinsurance, we estimate what you owe us based on our fee arrangement with your insurance company. For a counseling visit, the insurance fee might be $110, of which we would expect $33 coinsurance (30%). We charge you $30 at the time of visit, and adjust later for the remaining $3 once we receive a response your insurance plan.

$5.00 Collection Efforts Per Visit


$5.00 Collection Efforts Per Visit

We operate a mostly virtual practice. This means our front desk does not have the ability to speak to you at each visit, as you connect with our providers directly via video. You are still responsible for being in touch with us before/after each visit to pay your portion of the cost of the visit. If you do not make a payment for the visit within 5 days of your appointment, we add a $5.00 charge to your bill for the visit. These fees can add up; please be in touch with us to ensure you do not incur these fees.

Treatment Services


Treatment Services

The grid below shows our services and the typical frequency to be expected in treatment. Treatment services will vary based on your individual course of treatment.

Authorization to Pay Benefits to Kemet


Authorization to Pay Benefits to Kemet

In consideration of Kemet Health rendering treatment to me without immediate compensation, I irrevocably authorize and assign my right to payment of Kemet’s bill for treatment rendered to me out of the proceeds of any judgment or settlement in my case, and furthermore, from any insurance company providing coverage to me for such expenses. I understand, authorize, and agree that no payment due me under my contract for insurance shall be made to me for any other medical expenses until Kemet Health’s bill for my treatment is paid in full.

Secondary Government Payers


Secondary Government Payers

Kemet does not accept Medicare or Medicaid insurance plans at this time. As a result, while these plans would normally pay patient balances, you will be held accountable for these costs. You agree to pay the amount that Medicare/Medicaid normally “covers”. This is often a co-pay or deductible from your insurance. If you have questions contact our front desk.

"In signing below, I understand and agree to the above fee schedule & billing policies.”
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

E-signature image
Kemet Health