Financial Agreement

The  responsible party is the person who is ultimately responsible for  payment for therapeutic services. By signing this agreement, you are  indicating that you are the responsible party, and that you agree with  the following:

1. •Payment  for services is expected at the time of your visit. Payment or  co-payment for services is due at the beginning of the session.
   
    
2. •Appointments must be cancelled at least 24 hours in advance to avoid incurring a charge.
   
    
3. ‣The fee for late cancellations or failed appointments is equal to the charge for a full session.
   
    
4. ‣Insurance  will not pay for late cancellations or failed appointments. In the  event of a late cancellation or failed appointment you are responsible  for the entire fee for that service and not just your co-payment. The  fee for a late cancellation or failed appointment when you have  insurance therefore includes the portion typically paid by your  insurance for a treatment session and your co-payment.
   
    
5. •There will be a $35 service fee on all returned checks.
   
    
6. •You will be responsible for any charges incurred if legal or collections services are required for delinquent accounts.
   
    
7. •You  agree to provide me with information about changes in your insurance  coverage as soon as possible. If coverage terminates for any reason, you  are responsible for all fees denied by your insurance due to lack of  coverage.
   
    
8. •Services  such as letters written on behalf of clients, written reports or  assessment, appearance at court or school meetings are subject to a fee  based on the time involved. These fees may not be covered by your  insurance. Fees for legal appearances may be significantly higher than  standard fees.
   
    
9. •I  will provide you with a statement at the end of each month listing the  dates of services, fees for services and amount of payment or co-payment  paid. For individuals covered by PPO insurance plans that call for you  to submit receipts for reimbursement, these invoices will serve as  statements for that reimbursement process.
   
    
10. •As  per our agreement and/or my agreement with your insurance carrier, your  fee or co-payment for therapeutic service will be at the rate of ______  per 50-minute session.
    
     

Signed by the responsible party for therapeutic services acknowledging and consenting to this financial agreement.

Matthew Gerst, Ph.D.