Waiver of Insurance Billing for Private Pay Clients

Waiver of Insurance Billing for Private Pay Clients

Lisa M Nardi P.C.
I,
Name

First NameLast Name
have chosen to be a private pay client. This means that at the time of service I will be paying by cash, check, or credit card. Lisa M Nardi will not bill insurance for services provided under this arrangement. No forms will be produced now, or in the future, for you or us to submit for insurance billing.
Agreed Upon Private Pay rate for one hour of Psychotherapy:

$ 125
Initials*
I agree to:

1) I am responsible for any and all charges incurred from therapy sessions with Lisa M Nardi P.C.

2) pay at the time of service

3) waive insurance billing by Lisa M Nardi P.C.

4) notify Lisa M Nardi P.C. of a desire to change this agreement prior to private payment for a session
Client name (please print):
Client signature:

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