I, the client or the client, have been notified that my health insurance plan may deny payment or full coverage for psychotherapy services provided by Light On Anxiety, PC. I further certify that due to my current financial situation, I cannot afford the full fee rate of $180/60-minute session. I therefore request that my fee be adjusted in the event that it is not covered by my health insurance plan.
I understand that I am agreeing to the following payment plan between myself and Light On Anxiety, PC.
I understand that I am responsible for paying any co-payment, co-insurance and deductibles that my insurance does not cover. In the case that my insurance denies payment or full coverage, I understand that I am responsible for payment of services rendered at a rate of $120/60-minute session.
I further understand that I will not be charged for any appointments that are cancelled at least 24 hours in advance. I understand that appointments not cancelled at least 24 hours in advance are subject to a cancellation fee of $40. I understand that I am solely responsible for all these charges as they apply.
I acknowledge that a continuance of sliding scale benefits is not guaranteed and is subject to modification and/or elimination at the sole discretion of Light On Anxiety, PC. I further acknowledge that if my account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, Light On Anxiety, PC has the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require disclosure of otherwise confidential information.
Any questions or concerns that I may have had concerning this agreement were answered or discussed with one of the staff members at Light On Anxiety, PC.
