Terms of Payments

Payment (e.g. full payment, deposits) is due at the time services are rendered.  Please note that we are not in network with insurance plans and we do not bill insurance directly.  This will be your responsibility.  We will provide you with an Itemized Receipt referred to as a “Superbill”.  The Itemized Receipt  contains information that your insurance company needs to process your claim.  Ultimately patients are responsible for their account balance.

Since we are out of network providers with insurance companies  it is your responsibility to know if your health plan includes out of network benefits. If you have any questions about whether a certain procedure is covered, it is important that you call your insurance company and find out exactly what your plan covers.

For your convenience, we accept cash, checks, debit, and credit cards including Visa, MasterCard, Discover. We cannot guarantee that your HSA, HRA, or Benefits credit card will work in our office.

Self Payment Discount

Payment in full at the time of service using cash or check and without using insurance will receive a 5% self-pay discount on the overall fee.  These discounts do not apply to Groups and Clubs, or Classes. These services are already offered at a discounted rate.  In addition, no discount is offered with use of credit cards or HSA cards due to service fees associated with credit card processing/merchant services.


Appointment Cancellation

We understand being charged a late cancellation fee can be frustrating for our patients so we’d like to explain our philosophy on the importance of collecting late cancellation fees. When a patient cancels with less than  24 hours for therapy appointments and 48 hours for testing appointments, more than likely the clinician is unable to fill that slot. The patient will be subject to a fee, because a time commitment is made to you and is held exclusively for you.

Release of Medical Records

If you wish to release your medical records to another healthcare provider or someone else, you must sign an Authorization to Release Medical Records Form with that office/facility. Once our office receives the signed Authorization to Release Medical Records Form  we will process the request. Most requests are handled in seven to ten business days.

For a copy of your mental health and/or medical records or other protected health information please contact office at (503) 352-0240 or email at [email protected] and request a Patient Request for Access to Protected Health Information Form be sent to you. Please complete the form and fax your request to (971) 279-5635 or email your request to [email protected].


Forms Completion

Our practice is committed to providing high quality care to our patients. As part of the care process our providers will complete forms for schools, camps, etc. Since all forms require our signature, we are personally responsible for the accuracy of the information provided. Incomplete or inaccurate information may have far reaching consequences for your case. Filling out forms thus requires careful consideration and considerable amount of time.

Therefore, it is our office policy to charge for the completion of any form as follows:

* Processing fee of $25 per form, and
* Completion fee of $5 per each page.

We cap the charge at $50 maximum per form. We will complete the form and fax it to the designated recipient (or return it to you if you prefer) within 5 business days of the receipt of payment.

Please email the specific form you would like us to complete to [email protected] or fax it to 971-279-5635. Once received, we will send you an invoice outlining the cost to complete the form. To avoid delays, please make the payment once the invoice is received.

If the form to be completed was sent to us by an organization, we will notify you of the exact amount due. We may also request completion of an Authorization to Release Medical Records. The form will be completed and sent to you (or the requester) within 5 business days after payment is received.


If you have any questions about this Privacy Statement please contact us:

New Horizons Wellness Services, LLC
13333 SW 68th Parkway, STE 020
Tigard, OR 97223
(503) 352-0240
(971) 279-5635 (fax)


This Privacy Statement applies only to information collected through our Website. Our Clinic collects information about you through the information you provide to us. On some areas of our Website, we may collect certain information that you provide in order to register for services or request additional information. Such information may include:

  • Information you enter in forms and optional surveys
  • Demographic information, such as zip code, age gender
  • Information provided in e-mail requests and communications
  • Contact information, such as name, mailing address, e-mail address and phone number
  • Information provided in connection with online registration for groups or other events offered through our Website
  • Patient contact information, such as name, mailing address, phone number, e-mail address and medical and insurance information


Our Clinic may disclose information you provide to us to independent contractors, service providers and consultants, who assist us in providing healthcare services to you. However, we will only share such personally identifiable information, as we deem necessary for them to carry out their obligations to our Clinic.

Our Clinic may also disclose personal information it has collected if necessary to fulfill our service obligations or if we are required to do so by law, or in our good faith judgment, such action is reasonably necessary to comply with the legal process.


Our Website may offer links to other Websites. Please be aware that we are not responsible for the privacy Practices of such linked Websites, including Websites of our partners. We encourage our users to be aware when they leave our Website to read the privacy statements of each Website that collects personally identifiable information. This statement applies solely to information collected by our Website.


Unfortunately, no data protection method or combination of methods can be guaranteed 100 percent secure. We strive to protect your personal information as described throughout this policy, but we cannot ensure or warrant our ability to do so. As a result, you use our content, products, and services at your own risk. We will not be liable for disclosures of your personal information due to errors in transmission or unauthorized acts of third parties.

Thank You

New Horizons Wellness Services, LLC