Fee, confidentiality and service agreement

William F Martin
1300 West Belmont
Chicago, Il 60657
312-409-0632

Service and Fee Agreement Fee Policy, Confidentiality Statement, and Consent for Services

Name:

Agreement Summary:

  • Payment is expected at the beginning of each session.
  • Client is responsible to confirm all details related to insurance benefits, including deductible and co-payments.
  • Missed or “cancelled within 24hrs” sessions will be charged full fee.
  • Strict confidentiality will be maintained except when safety or the well-being of a minor or another person is at risk.

Fee Agreement

  • By signing below I am indicating that I have read the above statements on fees, payment, and confidentiality policies.
  • I have discussed these conditions with William Martin, LCSW and have had the opportunity to ask any questions. My questions have been answered to my satisfaction.
  • I understand and agree to meet my financial responsibilities in receiving treatment and services in this practice setting.
  • I understand that any unpaid balance in my account may be sent to a collections agency after 90 days of failure to pay.
  • I further agree and permit the use of a credit card I submit to be used for the payment of co-payments, deductibles or other balances in my account.
  • I understand I am giving permission for any confidential information to be provided to my insurance company for the purposes of authorizing insurance reimbursement.

Credit Card Information:

Name on Card:CC #:

Expiration Date:

Authorization:

I have read the above agreement, understand the policies and procedures presented, had the opportunity to ask any questions, and my signature below indicates my agreement to these policies and procedures.
Client name (please print):

Signature:

Date: