Forms and Insurance

Northland Counseling has adopted the following policies for charges for healthcare services:

We will charge persons receiving health services at the usual and customary rate prevailing in this area. Health services will be provided at no charge, or at a reduced charge, to persons unable to pay for services. In addition, persons will be charged for services to the extent that payment will be made by a third party authorized or under legal obligation to pay the charges.

We will not discriminate against any person receiving health servcies because of their inability to pay for services, or because payment for the health services will be made under Part A or B of Title XVIII ("Medicare") or Title XIX ("Medicaid") of the Social Security Act.

We will accept assignment under the Social Security Act for all services for which payment may be made under Part B of TItle XVIII ("Medicare") of the Act.

We have an agreement with the State agency which administers the State plan for medical assistance under Title XIX ("Medicaid") of the Social Security Act to provide services to persons entitled to medical asssistance under the plan.

FORMS
A set of forms will be provided at your first visit. If you prefer, you can print them out here and complete them ahead of time to bring with you. Most forms only require your signature. If you have any questions about these forms, call our office or bring them up with your therapist at your first appointment.

Adult Initial Paperwork

Child Initial Paperwork

If you would like a copy of our Notice of Privacy Practices, please click here.

HRSA Service Statement

Northland Counseling Service Statement

Sliding Fee Scale Application

Sliding Fee Scale Poverty Guidelines

Grievance Procedure- Read Only

FEES
Northland Counseling Services accepts many insurance plans, which frequently cover part or all of the cost of therapy. We also accept Medicare, Badger Care, and Medical Assistance, client payment options are also available.  Northland Counseling Services will offer a Sliding Fee Discount Program to all who are unable to pay for their services. Northland Counseling Services will base program eligibility on a person's ability to pay and will not discriminate on the basis of age, gender, race, sexual orientation, creed, religion, disabilty, or national origin.  The Federal Poverty Guildlines are used in creating and annually updating the sliding fee schedule (SFS) to determine eligibility. 

If you will be using your insurance plan, please bring your insurance card to your first appointment. We ask that co-pays or payments toward your deductible be made at the time of service.  Northland Counseling Services does not accept credit card or debit card payments at this time.

If you have any questions about insurance or billing, please contact our billing manager at 715-634-0222.