OFFICE USE ONLY Iowa or Nebraska    (circle one)   Cash or Discount

 

SPENCE COUNSELING CENTER, P.C.

 

CLIENT AND INSURANCE FEE AGREEMENT

 

                                                                                                           

Client Name: ____________________________________________________________

 

Insurance Company: ______________________________________________________

 

Therapist Name: __________________________________________________________

 

Therapist – In or Out of Network: ____________________________________________

 

Does Client Have Covered Insurance Benefits? _________________________________

 

Is an Authorization for Services Required? _____________________________________

 

What is Your Deductible? ___________________    Has it Been Met Yet? ___________

 

What is Your Co-Pay for Each Visit? _______________

 

Do You Have a Financial Hardship? ________________  If Yes, Indicate Below:

 

________________________________________________________________________

 

What is Your Agreed Fee per Session Amount?

 

Evaluation _$160________       Individual _$115________        Family _$145_________        

 

Group _$65____________        MBTI/TJ Tests _$60_________

 

NOTE:  Your policy may have some exclusions and/or restrictions of services, and may be subject to deductibles and co-insurance.  Benefits are determined when services are billed to your insurance company.  You will be responsible for services not covered or paid. 

 

PAYMENT IS DUE WHEN SERVICES ARE RENDERED.  YOU WILL BE RESPONSIBLE FOR PAYMENT AND BILLED FOR MISSED APPOINTMENTS OR CANCELLATIONS NOT MADE WITHIN 24 HOURS.

 

My signature below demonstrates that I have read, understand, and agree to the above. 

 

_____________________________________________                  __________________

Client, Guardian, or Policy Holder Signature                                          Date

 

______________________________________________

Therapist Signature