Important Information Regarding Medi-cal, Medi-care, and Other State– and Federally– Funded Insurance
Please read through this document, whether or not you currently have or are eligible for medi-cal, medi-care, or related programs. The information included in this document applies to individuals who currently carry insurance coverage for behavioral health benefits via one of these insurance programs, as well as applying to anyone who at any point after treatment begins becomes eligible to participate in, or begins participating in, any of these programs. This document will serve as a mutually agreed upon “private contract” between the professional therapist Finley Terhune and you, and/or those who are medically and legally allowed or required to consent to therapy for you, or who agree to provide payment for therapy which you receive.
Therapeutic Services with Finley Terhune
I, Finley M Terhune, LMFT 112607, am excluded from Medicare under Sections 1128, 1156, or 1892 of the Social Security Act.
What this means is that individuals who currently receive coverage from, are eligible for coverage from, or who may at some point become eligible to receive or begin receiving coverage from, programs such as Medi-cal, Medi-care, and related insurance plans are not able to receive reimbursement from these programs for therapy services provided by Finley M Terhune.
What is the biggest take away from the following information, in more plain language? As a medi-care or medi-cal recipient, you may be able to receive therapy services cheaper by seeking a provider considered “in network” or “participating” with medi-care or medi-cal. That could be a result of you not paying the provider at all, or by receiving reimbursement from your insurance for some part of what you pay to the provider.
While you will receive therapeutic services which would be “covered services” were you to work with a therapist/provider enrolled in the applicable insurance network, you will not be reimbursed and will not be eligible for reimbursement, as Finley Terhune is not a participating provider. It is your right to receive services from providers who are considered “participating” or “in network” providers with your insurance plan, and if possible upon request Finley Terhune will provide you information on how to reach out to your insurance plan to receive support in locating participating, covered providers who may be appropriate to your care needs.
If you were to receive these therapy services through a participating provider, there would be a maximum amount they would be allowed to charge you for services, which is legally mandated and maintained, and can generally be found by using the physician fee schedule lookup tool found at https://www.cms.gov/medicare/physician-fee-schedule/search/overview (as of 6/19/2025). These charge, fee, and cost limitations do not apply to services that are provided to you by Finley M Terhune.
While I generally see people who either have, or are eligible for, these coverage benefits on a deeply steep discount far below either my out of pocket rate or the “allowed amount” maximum, it is important that you are made aware that should these limits ever change such that our agreed fee amount is higher than the “allowed amount” on the plan, Finley Terhune is not subject to that fee maximum.
By signing here, you are indicating that you understand and agree with the fact that you will pay for therapeutic services provided by Finley Terhune directly to them as the provider, and further you are indicating that you understand and agree with the fact that there is no outside agency or agreement which will define either the lower or upper limit of an amount that Finley can charge you for a given therapeutic service.
[Signature]
By signing here, you are indicating that you understand and agree that neither Finley Terhune, you yourself, nor any person, entity, or agency on your behalf, will file claims for reimbursement for these services to medi-cal, medi-care, or any related insurance plan.
[Signature]
By signing here, you are indicating that you understand and agree with the fact that by signing this “private contract”, you are agreeing to pay for services at a rate discussed with and documented by Finley Terhune, with the knowledge that you are never obligated to receive these services from Finley Terhune, and that you have the right to seek out a provider who is covered by your relevant insurance plan(s).
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By signing here, you are additionally stating that you are aware you have the right to see a “participating” or “in network” provider that your insurance would cover and accept claims and/or reimbursement for. Further, if you at any point are eligible to receive coverage through “medigap” or other supplemental insurance plans, you are generally not eligible to receive reimbursement for these therapy services as provided by Finley Terhune, according to the same parameters outlined in the rest of this contract.
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By signing here, you are indicating that you are not signing this document during a time at which you are in need of emergency care or immediate services for life-saving care.
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By signing here, you are indicating that you feel you have had the opportunity to ask and receive clarity on any individual part of this private contract to your satisfaction.
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By signing here, you are indicating that you understand and agree with the fact that this document serves as a private contract which you are agreeing to enter into for the purposes of receiving therapeutic services from Finley M Terhune. The amount that you pay will not be determined by any outside entity or agency, but will be an ongoing conversation between yourself and Finley Terhune, and/or as relevant by the financially responsible party co-entering into this agreement on the patient’s behalf (such as a parent or legal representative).
[Signature]
As of this writing, the current status of Finley Terhune as an “opt out” provider for Medi-care/Medi-cal and related insurance programs is expected to renew in June of 2027, and every two years there-after. Should you still be receiving, or return to receiving, services from Finley M Terhune at that time, you can anticipate signing a renewal of, or new, private contract document such as this.