Intake, Service and Fee Agreement (Best to use Mozilla Firefox Browser)

Intake, Fee and Service agreement

(1) Name:

Address:

City, State, Zipcode:
Birthdate:

Home Phone:

Cell Phone:

Email:

Insurance info:

ID#

Group #

(2) Name:

Address:

City, State, Zipcode:
Birthdate:

Home Phone:

Cell Phone:

Email:

Insurance info:

ID#

Group #

Service Agreement Summary:

Payment in-full, including deductibles and co-payments are expected at the beginning of each session.
Please initial_____.

•    I understand it’s my responsibility to confirm all details related to insurance benefits, including deductible and co-payments.

•    All scheduling and cancellations will be completed through the online (schedulicity) program.

•    Missed or “cancelled within 24hrs” sessions will be charged full fee and can not be billed to your insurance company.

•    Couples counseling means both partners are seen together at the time of the session, never individually. If one member is sick, the session should be cancelled.
•    Strict confidentiality will be maintained except when safety or the well-being of a minor or another person is at risk.

•    I have been given access to the HIPPA statement and understand William Martin, LCSW is the manager of the HIPPA  program.

•    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 understand I am giving permission for any confidential information to be provided to my insurance company for the purposes of authorizing insurance reimbursement, including the use of a mental health diagnostic code which will become part of my permanent health records.

•    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.
Please provide a credit card number for me to charge for the first sessions until your insurance company begins to reimburse me for our work together. Often, there is a deductible to be met and this can be a few hundred to several thousand dollars. PLease refer to the insurance questions link when you call your insurance company.

Credit Card Information:

Name on Card:

CC #:

Expiration Date:

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.

(1)Client name (please print):

Signature:

Date:

(2)Client name (please print):

Signature:

Date: