MINDDEVELOPERS COUNSELING & SUPERVERVISION PC FINANCIAL AGREEMENT AND PROMISE TO PAY ACCOUNT

For in and consideration of services rendered and to be rendered to will promise to pay MindDevelopers Counseling & Supervision PC  (MindDevelopers I understand the total charges are due when services are rendered. I agree to make available any and all insurance information to MindDevelopers Counseling & Supervision PC and/or billing personnel. I understand that MindDevelopers Counseling & Supervision PC bills from One hundred and twenty five dollars to one hundred and eigthy-five dollars ($125-$185) for sessions lasting 45-60 minutes, based upon therapist and their licensure. I agree to provide insurance claim forms of any insurance company and/or will complete the HCFA 1500 form. I agree to assign any and all benefits to MindDevelopers Counseling & Supervision PC and sign in the designated areas on the insurance claim form. I agree to pay the entire deductible amount, as well as any co-payment amount due. I understand that I am financially responsible for missed appointments ($75 per occurrence), in which I do not give a 24- hour notice and that my credit card will be charged if I do not give the 24 hour notice. The fee for a missed visit (in which less than 24- hour notice is given, including weekends) is $75.00. In addition, if my insurance company fails to pay for each date of service with in four weeks, I will be billed for the date of service. I will be provided with a super bill so you can be reimbursed by my insurance company. In this process, if payment is received after the four week date of service; I will be reimbursed by MindDevelopers Counseling & Supervision PC. By signing this agreement I completely understand that it is my responsibility to handle all insurance matters, including getting authorization and untimely payment by my insurance company (more than 4 weeks after date of service I understand that MindDevelopers Counseling & Supervision PC will file each date of service one time and any rejection payment from my insurance company will be taken care of by me. I understand that I am financially responsible for all charges not covered or denied by my insurance company. I understand that if I should receive payment from the insurance company by mistake, which payment was/should be assigned to MindDevelopers Counseling & Supervision PC, I will sign this payment over to MindDevelopers Counseling & Supervision PC and MindDevelopers Counseling & Supervision PC has the right to seek legal action to receive payment for this agreement, relative to payment fees, MindDevelopers Counseling & Supervision PC shall be entitled to reasonable attorney fees and cost of collection.

I further understand that no records (written or verbal) will be released to me or on my behalf if I have an outstanding balance due to MindDevelopers Counsleing & Supervision PC. MindDevelopers Counseling & Supervision PC does not accept checks. Please provide us with your credit card information. The card will ONLY be billed for tele-mental health services, if less than 24 hour notice is given, or on accounts that are 60 days past due:

 

By signing below, I am agreeing to the terms and conditions of this financial contract.

promise to pay MindDevelopers Counseling & Supervision PC (MindDevelopers Counseling & Supervision PC I understand that MindDevelopers Counseling & Supervision PC bills at the rate of $200.00 per hour for court attendance. I agree to provide MindDevelopers Counseling & Supervision PC with my credit card information. I understand that the hourly rate begins when the therapist leaves their location. I understand that a fee for two hours will be paid prior to court attendance, ($400.00) and is non-refundable if less time is needed. If the court attendance exceeds two hours, I understand that my credit card will be billed for the remaining time. In addition, I understand that I am not paying for the therapist's testimony; I am paying for their time. Therefore, the fees are expected to be paid regardless of whether the therapist testifies or not.

 

On call policy:

I understand that if I request my therapist to be on-call for court attendance, MindDevelopers Counseling & Supervision PC  bills at the rate of $75.00 per hour for on-call. I agree to provide MindDevelopers Counseling & Supervision PC with my credit card information in order for the payment to be charged. I understand that the hours I am requesting the therapist to be on call will immediately be charged to my credit card, and is non-refundable.

Communication with Attorneys/Other professionals/Report writing:

I understand that MindDevelopers Counseling & Supervision PC bills at the rate of $125.00 per hour for any type of communication with attorneys/other professionals/report writing (phone calls, letter writing, email, consultation, etc I understand that I will need to provide my credit card information prior to any communication my therapist will have with my attorney/outside professional. I understand that a minimum of 30 minute increments will be billed to my credit card and is non-refundable.

Records Request

For each separate request, MindDevelopers Counseling & Supervision PC bills a flat rate of $25 for records to be copied and faxed/given to the client. If records need to be mailed, an additional fee of $10 is assessed to cover certified mail and postage. After payment is received and processed, please allow up to 7 business days for copies to be provided and/or mailed. I also understand that no disability paperwork, work leave of absence, FMLA, etc will be completed before the third (3rd) session.

MindDevelopers Counseling & Supervision PC does not accept checks. Please Provide Credit Card Information:

I further understand that no records (written or verbal) will be released to me or on my behalf if I have an outstanding balance due to MindDevelopers Counseling & Supervision PC. I understand that I am financially responsible for all charges and MindDevelopers Counseling & Supervision PC as the right to seek legal action to receive payment for this agreement, relative to payment fees, MindDevelopers Counseling & Supervision PC shall be entitled to reasonable attorney fees and cost of collection.

By signing below, I am agreeing to the terms and conditions of this financial contract.