Common Contracts
1 similar Fee and Payment Agreement contracts
Fee and Payment AgreementFee and Payment Agreement • June 20th, 2016
I, , agree to pay Lisa Inoue, LMSW PLLC the private pay fee of $ per session (60 minutes) for psychotherapy services for myself/child given her non-participation with my insurance company or my desire to not utilize my insurance benefit for my mental health treatment. In the event that I choose to use my insurance coverage and Lisa Inoue LMSW PLLC is a participating provider, I understand that my co-pay is $ . Sessions that exceed 60 minutes for will be prorated at the agreed upon rate of $ for those paying out-of-pocket fees. I understand that payment of the agreed upon fee, or insurance co-payment, will be made at the time of service unless other arrangements are made. I further understand that I am responsible for paying all balances not paid by my insurance company within 30 days, and I hereby agree to allow the release of basic information to a collection agency should I fail to pay any outstanding balances. I agree to pay any and all fees incurred by Lisa Inoue, LMSW PLLC that ma
