Change in Entropy Hypnotherapy
Website: https://www.change-in-entropy.com/
Effective Date: March 17, 2026
Last Updated: March 17, 2026
Contact Information
Change in Entropy Hypnotherapy
2862 Change Street, Unit A
Los Alamos, NM 87544
Email: [email protected]
Phone: (907) 278-1180
1. Purpose
This Financial Policy explains the fees, payment expectations, cancellation terms, billing practices, and related financial responsibilities for services provided by Change in Entropy Hypnotherapy.
By scheduling or receiving services, you acknowledge that you have read, understood, and agree to this Financial Policy.
2. Payment Responsibility
You are responsible for payment of all fees for services provided to you unless otherwise agreed in writing.
Payment is due at the time of service, unless a different arrangement is made in advance in writing.
If a parent, guardian, personal representative, or other responsible party signs on your behalf, that person may also be financially responsible to the extent permitted by law.
3. Fees for Services
Current fees may include:
Initial consultation: Complimentary
Standard session: $[insert amount]
Follow-up session: $[insert amount]
Package or program rate: $[insert amount or terms]
Forms, letters, summaries, or special administrative requests: $[insert amount, if applicable]
Fees are subject to change. Updated fees will apply prospectively and will be communicated through the website, scheduling platform, intake materials, or direct written notice.
4. Accepted Payment Methods
We accept the following forms of payment:
Credit card
Debit card
HSA/FSA card, if applicable
Cash
Other: [insert accepted methods]
Payment method details may be collected and stored through a third-party payment processor, scheduling platform, or practice management system, subject to applicable privacy and security protections.
5. Card on File, If Used
If the practice maintains a card on file, you authorize Change in Entropy Hypnotherapy to charge that card for:
session fees
late cancellation fees
no-show fees
unpaid balances you have authorized us to collect under this policy or other written agreement
You will be informed of charges as reasonably appropriate.
6. Insurance and Self-Pay Status
Choose the version that matches your practice:
Option A: Self-Pay Practice
Change in Entropy Hypnotherapy is a self-pay practice and does not bill insurance directly. Clients are responsible for the full fee for services unless otherwise stated in writing.
Option B: Limited Insurance Participation
Change in Entropy Hypnotherapy may accept or assist with certain insurance arrangements as stated separately in writing. You remain responsible for any amount not paid by insurance, including deductibles, coinsurance, noncovered services, and denied claims.
If you are uninsured or choose not to use insurance for a service, federal law may entitle you to a Good Faith Estimate of expected charges in qualifying situations.
7. Good Faith Estimate
If you are uninsured or self-pay, you may have the right to receive a Good Faith Estimate of expected charges before scheduled services in situations covered by federal law. If you schedule far enough in advance or ask for an estimate, we will provide one when required. If your final bill is at least $400 more than the estimate from this provider, you may have the right to use the federal Patient-Provider Dispute Resolution process.
8. Out-of-Pocket Payment and HIPAA Restriction Requests
If HIPAA applies to your care and you pay for a service or item in full out of pocket, you may request that we not disclose information about that item or service to your health plan for payment or health care operations, unless disclosure is otherwise required by law.
Any such request should be made in writing.
9. Cancellation Policy
We ask that you provide at least [insert number] hours notice if you need to cancel or reschedule an appointment.
If sufficient notice is not given, the following may apply:
Late cancellation fee: $[insert amount] or [insert percentage]% of the scheduled fee
No-show fee: $[insert amount] or [insert percentage]% of the scheduled fee
A cancellation is considered late if it occurs less than [insert number] hours before the scheduled appointment time.
10. Late Arrival Policy
If you arrive late, your session may be shortened to avoid delaying other appointments.
Unless otherwise decided by the practice, you remain responsible for the full scheduled session fee.
If you are more than [insert number] minutes late, the appointment may be treated as a missed appointment and rescheduled.
11. Missed Appointments and Repeated Scheduling Issues
Repeated no-shows, repeated late cancellations, or repeated late arrivals may result in:
advance payment requirements
a card-on-file requirement
reduced scheduling priority
limitation or discontinuation of future scheduling
12. Refund Policy
Unless otherwise stated in writing:
fees for completed sessions are nonrefundable
missed appointment fees and late cancellation fees are nonrefundable
deposits, prepaid packages, or reserved-session fees are governed by the written terms provided at purchase
Any exception is at the sole discretion of the practice unless required by law.
13. Prepaid Packages, Programs, or Deposits
If you purchase a package, series, or prepaid program, the terms of that purchase will apply in addition to this policy.
Those terms should specify:
services included
expiration date, if any
refundability
rescheduling rules
whether unused sessions may be transferred or forfeited
14. Returned Payments, Chargebacks, and Failed Transactions
If a payment is declined, returned, disputed, reversed, or charged back, you remain responsible for the balance due.
The practice may pause future appointments until the balance is resolved.
Any returned-payment fee or reasonable administrative fee permitted by law may be charged if disclosed in advance.
15. Outstanding Balances
Balances that remain unpaid may result in:
suspension of future scheduling
requirement of prepayment for future services
additional collection efforts consistent with applicable law
Before any outside collection action is taken, the practice may attempt to contact you using the contact information you provided.
16. Fees for Records, Letters, and Administrative Requests
Routine treatment records are handled according to applicable law and privacy rules. Special requests, such as custom letters, forms, summaries, court-related documents, or non-routine administrative work, may be billed separately at:
Flat fee: $[insert amount], or
Hourly rate: $[insert amount] per hour
You will be informed in advance where feasible.
17. Minors and Third-Party Responsibility
If services are provided to a minor or to a person represented by another legally authorized person, the signing parent, guardian, or representative may be financially responsible for payment unless otherwise agreed in writing.
18. Changes to This Financial Policy
We may revise this Financial Policy from time to time. Any updated version will be posted or otherwise made available and will apply to services provided after the effective date of the revised policy.
19. Contact
Questions about this Financial Policy should be directed to:
Change in Entropy Hypnotherapy
2862 Change Street, Unit A
Los Alamos, NM 87544
Email: [email protected]
Phone: (907) 278-1180
Client Acknowledgment
I acknowledge that I have read and understand the Financial Policy of Change in Entropy Hypnotherapy. I agree to be financially responsible according to its terms.
Client Name: _________________________________________
Client Signature: ______________________________________
Date: ________________________________________________
Personal Representative, If Applicable
Name: ________________________________________________
Relationship to Client: __________________________________
Signature: ____________________________________________
Date: ________________________________________________