HEALTH INSURANCE/FEE AGREEMENT

Client Name (First and Last)*
Date of Birth (of Client)*

MonthDayYear
DOB
Address*

Street Address

Street Address Line 2 (if needed)

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Social Security Number
Only needed if you have a Medicaid Insurance product, United Healthcare, or Tricare
Health Insurance Policy Holder's Name:*
This person owns and pays for the policy
Policy Holder's date of birth:*
Insurance Carrier:*
Name of client's Insurance Company
Insurance Member ID#:*
Group #:
HEALTH INSURANCE VERIFICATION/FEE AGREEMENT

Insurance may pay all or a portion of your fee which is determined by your explanation of benefits statement after claims are filed to your insurance company. Each contract rate is based on your insurance and whether your provider is in-network. The financially responsible person is responsible for the amount determined by your insurance company. We use Square Reader Virtual terminal and accept cash, credit card, or health savings accounts. A monthly statement will be mailed to your home address with the balance of your patient account if there is an outstanding balance. Missed appointments, same-day cancelations, or less than 24 hours notice results in a $35.00 fee.

ALL CO-PAYS ARE DUE AT THE TIME OF SERVICE
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Full Fee per Service Cost
Initial Diagnostic Assessment $ 175.00
Individual Counseling (Psychotherapy) $ 170.00
Extensive phone consultation $ 30.00/min
Missed appointment $ 35.00 per visit
Subpoenaed to Court to testify $ 120.00/hour
Financially Responsible Person Signature (typically you if you are the adult client - the guardian if client is a minor)*

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