Referrals & Insurance


Referral Options

Self-referrals as well as referrals from mental health treatment providers and other service providers are accepted.

A referral form can be downloaded here and faxed to 712-566-5229. If you are a referring provider, please also have the client sign a Release of Information for your facility, which can also be found here, and fax the Release of Information in with the referral form, as well.


Various forms of insurance and self-pay are accepted. We are an In-Network provider for the following insurance companies: Aetna, Avera Health Plans, AmeriHealth Caritas, Amerigroup Iowa, Blue Cross/Blue Shield, Cigna, County Social Services, HealthPartners, Iowa Total Care, Medicare, Medicaid Iowa, Midlands Choice, Sanford Health, Tricare West, and United Healthcare. Please call our office to discuss your billing options. We also have a Sliding Scale Fee option upon request. Our Sliding Fee Scale Form and Application can be downloaded HERE.

Please know your health benefits before your appointment. All out of pocket/deductible/co-insurance and co-payments are due at time of service. Payment will be due prior to your appointment.

Due to the variations among insurance policies, it is difficult for Champion State of Mind to continuously know each person’s individual benefits. In most cases we can submit insurance claims on your behalf, however it is important that you understand your benefits and how to manage them.

Ultimately, it is the client’s responsibility to understand their insurance coverage. It is also the client’s responsibility to pay for their portion of the balance or the insurance portions of their balance if the insurance claim is denied.

Right to a Good Faith Estimate
As of January 1st, 2022, You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit

NOTICE TO PATIENTS: This practice serves all patients regardless of inability to pay. Discounts for essential services are offered based on family size and income. For more information, ask at the front desk or call our office at 1-800-592-0180. Thank you.