Financial Agreement & Appointment Reminders

a. I acknowledge that as a courtesy, MySpectrum Counseling & Coaching may bill myinsurance company for services provided to me

b. I agree to pay for services that are not covered, or covered charges not paid in fullincluding, but not limited to any co-payment, co-insurance and/or deductibles, or charges notcovered by insurance. I also understand that there is a $15 charge for not making a copay at thetime of my appointment and that a 1.5 percent charge will be added to my bill for each month astatement is mailed.

c. I understand that there is a $50 fee for returned checks.

d. I understand that if I do not show up for an appointment without calling or if I cancel on thesame day of my appointment, my credit card or account will incur a $55 fee. Appointments must be canceled 48 hours in advance to avoid a charge.

e. If I arrive 15 minutes late for my appointment, I understand that my therapist will notbe able to see me, I will be charged a No Show fee of $55, and I will have to reschedulemy appointment.

e. I acknowledge that MySpectrum Counseling & Coaching may utilize the services of a third-party business associate or affiliated entity as an extended business office (EBO Service) for I acknowledge that MySpectrum Counseling & Coaching may utilize the services of a third medical billing and servicing.

f. I hereby assign to, MySpectrum Counseling & Coaching any insurance or other third-party benefits available for health care services, provided to me. I understand, MySpectrum Counseling & Coaching has the right to refuse or accept assignment of such benefits. If these benefits are not assigned to MySpectrum Coaching & Coaching, I agree to forward all health insurance or third-party payments that I receive for services rendered to me immediately upon receipt.

g. I certify that any information I provide, if any, in applying for payment under Title XVIII (“Medicare”) or Title XIX (“Medicaid”) of the Social Security Act is correct. I request payment of authorized benefits to be made on my behalf to MySpectrum Counseling & Coaching, by the Medicare and Medicaid programs.

h. I agree that, in order for, MySpectrum Counseling & Coaching, or Extended Business Office (EBO) Servicers and collection agents, to service my account or to collect any amounts I may owe, I expressly agree and consent that, MySpectrum Counseling & Coaching or EBO Servicers and collection agents may contact me by telephone at any telephone number, without limitation to wireless, I have provided or, MySpectrum Counseling & Coaching or EBO Servicers and collection agents have obtained or at any phone number forwarded or transferred from that number, regarding the services rendered, or my related financial obligations. Methods of contact may include using pre-recording/artifical voice messages and/or use of an automatic dialing service, as applicable.

MySpectrum Fee Schedule / Self-Pay Rates

Initial Intake Assessment (60 minutes) - $115

Therapy Session (45-50 minutes) - $75

Therapy Session (60 Minutes) - $90

Family Therapy (w/client) - $90

Family Session (w/o client) - $90

Interactive Complexity Add-On - $25

Group Therapy - $40 per group

Life Coaching - Telehealth - $120 (50 to 60 minutes)

Life Coaching - In-Person - $175 (50 to 60 Minutes)

Mental Health Evaluation for Court, Lawyers (does not include fee for writing a report) - $250

Outside Office Work (Inpatient visits, Collaborative Services, Court appearances, etc.) - $100 per hour

Written Report (Court, Supervisors) - $100 per hour

Consultation - $100 for non client, $75 for current client

No Show/Late Cancellation Fee (less than 24 hour notice) - $55

Returned Check Fee (per check) - $50