Self-Pay Contract

Self-Pay Contract
Patient's Name*

First NameLast Name
Responsible Party's Name*

First NameLast Name
Initial next to each of the following to signify that you understand and agree to the terms:

1.Initial* I understand that I will be responsible for all charges related to the services provided to me by Arise Psychiatric Medical Group, Inc.

2.Initial* I understand that the charges presented to me are due in full on the day of the service, unless arrangements have been made with the physician.
3. Initial* I understand that these charges are solely in relation to professional services provided by the physician, and/or other services that are performed in the office.
SELF-PAY RATES
- Initial evaluation (40 - 60 minutes) - $400.00
- Follow-up appointment (20 minutes) - $250.00
By signing below I certify that I have read and agree to the forgoing, and that I am the patient, responsible party, or am duly authorized by the patient as the patient's general agent to execute the above and accept the terms.
Name*

First NameLast Name
Signature*

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Date*

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