<p> Wyoming Behavioral Institute – Outpatient Clinic in Laramie 504 S 4th Street Laramie, WY 82070 Phone: (307) 742-9700 Fax: (307) 742-9717</p><p>Thank you for considering us for your mental health needs!</p><p>Office Hours: 8:00 am – 5:00 pm Monday thru Friday. Closed weekends and holidays.</p><p>* The initial intake paperwork must be completed and returned to the office prior to the initial intake appointment being scheduled. * The first visit is a psychiatric evaluation that generally takes 60-90 minutes. The charge is variable based on medical complexity. It may take several visits to complete the evaluation. Acceptance for treatment is at the discretion of the provider. Follow-up appointments are typically scheduled for 30 minutes.</p><p>Billing – Insurance - Please call your insurance company to find out if the visit needs to be preauthorized Please come prepared with your insurance card. We will be happy to bill your insurance, and then the remaining balance will be billed to the responsible party. Without Insurance – bills will be sent directly to the responsible party Payment Arrangements - The Outsource Group at 866-247-0953 and ask to make a payment arrangement for Wyoming Behavioral Institute. They accept; cash, check, money order, Visa, MasterCard, American Express and Discover. Payments are not taken at this facility</p><p>Missed Appointments - You will be expected to pay for missed appointments unless you have given a minimum of one business day’s prior notice. Rebilling fees will be applied to unpaid balances after 60 days. This includes patients covered by Wyoming Medicaid and Kid Care. Insurance will not pay for missed appointments. If three appointments in a row are missed, clinic procedure is to administratively discharge the patient from the clinic for a period of six months. A certified letter will be sent to the responsible party notifying the patient of this. The patient will need to seek another facility to provide services. Wyoming Behavioral Institute Outpatient Clinic will provide a list of alternate providers. If the patient would like to return to the clinic after a sixth month period, the patient will need to call the clinic and the matter will be reconsidered by the provider and clinical staff to determine if it is appropriate for the patient to return for services. </p><p>****I have read, understand, and agree to the above information****</p><p>______Patient Name Patient/Guardian Signature Date</p>