Initial Telehealth Session Self-Pay

Cancellation Policy

Self-pay (out-of-network) clients: I will provide you with a superbill suitable for you to submit to your insurance. The superbill (which will also serve as a payment receipt) will be coded appropriately to the level of service provided during the visit. You agree to pay me at the time of the visit (cash, check, credit card, or FSA). The superbill will be provided to you after receipt of payment. Insurance (in-network) clients: Claims for my care will be submitted directly to Aetna, Wildflower (for Cigna) and The Lactation Network (for United and certain Aetna plans). Holistic Infant Feeding LLC will appeal all cost-sharing under the Affordable Care Act which states that lactation services are preventive and not subject to cost-sharing. If my insurance provider applies any portion to deductible or coinsurance and appeal attempts are unsuccessful, I will be billed for the services provided and my credit card on file will be charged. If that charge is unsuccessful for any reason, I will be invoiced and I agree to pay within 7 days for all applied charges for all visits. Holistic Infant Feeding LLC will submit a claim on behalf of myself and my babies. If any portion of either claim is applied to cost-sharing, I understand that I am required by law to pay cost-sharing to Aetna. My credit card will be charged upon receipt of the Estimation of Benefits (EOB) by Holistic Infant Feeding LLC. Every effort will be made to have my insurance recognize these claims as preventive and not subject to cost-sharing, and an appeal will be initiated. If successful, I will be refunded any amount that Holistic Infant Feeding LLC recovers from my insurer. If one of us (me or my baby) is on different insurance and therefore out-of-network for Holistic Infant Feeding LLC, I agree to pay per the visit cost breakdown below: Initial Home Visit Single baby: $225 Follow up Home Visit Single Baby: $190 Initial Home Visit Twins: $275 Follow up Home Visit Twins: $225 Initial Telehealth: $150 Follow up Telehealth: $130 I will receive a superbill for this amount and can submit for out-of-network insurance reimbursement. If I have different primary insurance that is out-of-network for Holistic Infant Feeding LLC, I understand that I must pay the full self-pay fee up front as a deposit. I will not be refunded for any amount either insurance applies to cost-sharing. I will only be refunded if and when Holistic Infant Feeding LLC rece

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