Fee Agreement and Cancellation Policy Sample Contracts

Fee Agreement and Cancellation Policy
Fee Agreement and Cancellation Policy • March 19th, 2022

Payment for services are due the day of each session. I understand that payment can be in the form of cash, check (made payable to Ventura Community Counseling), or credit card. My therapist may provide me with a receipt indicating payment, upon my request. My therapist reserves the right to periodically adjust this fee. I will be notified of any fee adjustment in advance.

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Fee Agreement and Cancellation Policy
Fee Agreement and Cancellation Policy • November 9th, 2018

Every insurance plan has different acupuncture coverage including co-pays, deductibles, rates of service, preauthorization required and number of visits per year. Some plans also have exclusions for this service such as diagnosis, facility or provider of service restrictions. It is the patient’s responsibility to know their coverage and benefits before receiving services. Seattle Acupuncture and Coaching does not verify patient eligibility and benefits and we do not guarantee coverage or payment by your insurance provider.

Jennifer L. Todd, LCSW, ACHT 87 Park Street
Fee Agreement and Cancellation Policy • October 7th, 2021

w I understand that I must give at least 24 hours notice to cancel or reschedule an appointment to avoid being charged for the reserved session time.

Fee Agreement and Cancellation Policy
Fee Agreement and Cancellation Policy • July 15th, 2019

Every insurance plan has different acupuncture coverage including co-pays, deductibles, rates of service, preauthorization required and number of visits per year. Some plans also have exclusions for this service such as diagnosis, facility or provider of service restrictions. It is the patient’s responsibility to know their coverage and benefits before receiving services. Seattle Acupuncture and Coaching does not verify patient eligibility and benefits and we do not guarantee coverage or payment by your insurance provider.

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