INDEPENDENT CONTRACTOR AFFILIATES FINANCIAL AGREEMENT & PERMISSION FOR TREATMENTContractor Affiliates Financial Agreement • August 6th, 2020
Initial Assessment by Therapist $130 Follow-up Therapy Sessions (Length Dependent) $100 -$125 Initial Assessment by Medication Provider $200 Follow-up Medication Management Services $100 FEES NOT COVERED BY INSURANCE INSUFFICIENT FUNDS FEE $40 COPIES OF MEDICAL RECORDS (paper or electronic) $20 + .50/page up to 50 pages, then.25/page LATE CANCELLATION (Cancellation less than 24hrs prior to scheduled appointment time.) $50 NO SHOW (Missing scheduled appointment without calling to notify provider.) $80 MEDICATION REFILL/FORMS/DOCUMENT/PHONE CALL $25.00 - $100.00 COURT APPEARANCE FEES $750.00 min (billed in 3hr increments) DELINQUENT ACCOUNTS 1.5% per month (18% per annum) plus court costs & attorney fees
