Standard Contracts
Fee Agreement and Financial PolicyFee Agreement and Financial Policy • June 21st, 2022
Thank you for choosing the Mindfulness Gym. Please review our Fee Agreement and Financial Policy, which describes our schedule of fees for services, charges not covered by insurance, and additional fees. Please be sure you understand the policies regarding our service rate, cancelations, missed appointments, methods of payment, insurance reimbursement, and past due accounts. If you have any questions about this policy, please ask your provider prior to signing this Agreement and Policy.
FEE AGREEMENT AND FINANCIAL POLICYFee Agreement and Financial Policy • February 14th, 2023
Thank you for choosing Dove Healing Center. Please review this Fee Agreement and Financial Policy (the “Agreement and Policy”), which describes my schedule of fees for services, charges not covered by insurance, and additional fees. Please be sure you understand the policies regarding cancelations and missed appointments, methods of payment, insurance reimbursement, and past due accounts.
FEE AGREEMENT AND FINANCIAL POLICYFee Agreement and Financial Policy • November 14th, 2022
Please review this Fee Agreement and Financial Policy (the “Agreement and Policy”), which describes my schedule of fees for therapy services, charges not covered by insurance, and additional fees for Emilee Conrad Counseling, LLC (“ECC”). Please be sure you understand the policies regarding cancellations and missed appointments, methods of payment, insurance reimbursement, and past due accounts. If you have any questions about anything, please ask me prior to signing this Agreement and Policy.
FEE AGREEMENT AND FINANCIAL POLICYFee Agreement and Financial Policy • April 25th, 2015
Thank you for choosing The Rock Counseling Group. Please review this Fee Agreement and Financial Policy (the “Agreement and Policy”), which describes our schedule of fees for services, charges not covered by insurance, and additional fees. Please be sure you understand the policies regarding cancelations and missed appointments, methods of payment, insurance reimbursement, and past due accounts. If you have any questions about anything, please ask your provider prior to signing this Agreement and Policy.
THE SOURCE BEHAVIORAL HEALTH FEE AGREEMENT AND FINANCIAL POLICYFee Agreement and Financial Policy • August 24th, 2020
Thank you for choosing The Source Behavioral Health. Please review this Fee Agreement and Financial Policy (the “Agreement and Policy”), which describes our schedule of fees for services, charges not covered by insurance, and additional fees. Please be sure you understand the policies regarding cancelations and missed appointments, methods of payment, insurance reimbursement, and past due accounts. If you have any questions about anything, please ask your provider prior to signing this Agreement and Policy.
FEE AGREEMENT AND FINANCIAL POLICY FOR INSURANCE & SELF-PAYFee Agreement and Financial Policy • March 25th, 2020
Thank you for choosing Grace Counseling Services of Winter Haven. Please review this Fee Agreement and Financial Policy (the “Agreement and Policy”), which describes our schedule of fees for services, charges not covered by insurance, and additional fees. Please be sure you understand the policies regarding cancelations and missed appointments, methods of payment, insurance reimbursement, and past due accounts. If you have any questions about anything, please ask your provider prior to signing this Agreement and Policy.
Yvette Melvin, Licensed Marriage and Family Therapist MFC#38114Fee Agreement and Financial Policy • February 3rd, 2021
Please review this Fee Agreement and Financial Policy (the “Agreement and Policy”), which describes the schedule of fees for services, charges not covered by insurance, and additional fees. Please be sure you understand the policies regarding cancelations and missed appointments, methods of payment, insurance reimbursement, and past due accounts. If you have any questions, please ask prior to signing this Agreement and Policy.
FEE AGREEMENT AND FINANCIAL POLICYFee Agreement and Financial Policy • May 25th, 2020
Fee Agreement and Financial PolicyFee Agreement and Financial Policy • April 6th, 2021
This contains important information regarding fees and insurance. Please review and make sure you understand the policy. If you have any questions, please discuss with your Therapist or the Program Assistant BEFORE signing.
FEE AGREEMENT AND FINANCIAL POLICYFee Agreement and Financial Policy • February 8th, 2014
Please review this Fee Agreement and Financial Policy (the “Agreement and Policy”), which describes my schedule of fees for therapy services, charges not covered by insurance, and additional fees. Please be sure you understand the policies regarding cancelations and missed appointments, methods of payment, insurance reimbursement, and past due accounts. If you have any questions about anything, please ask me prior to signing this Agreement and Policy.
FEE AGREEMENT AND FINANCIAL POLICYFee Agreement and Financial Policy • May 23rd, 2024
Please review this Fee Agreement and Financial Policy (the “Agreement and Policy”), which describes my schedule of fees for therapy services, charges not covered by insurance, and additional fees for Emilee Conrad Counseling, LLC (“ECC”). Please be sure you understand the policies regarding cancellations and missed appointments, methods of payment, insurance reimbursement, and past due accounts. If you have any questions about anything, please ask me prior to signing this Agreement and Policy.
FEE AGREEMENT AND FINANCIAL POLICYFee Agreement and Financial Policy • February 5th, 2021
Please review this Fee Agreement and Financial Policy (the “Agreement and Policy”), which describes my schedule of fees for therapy services, charges not covered by insurance, and additional fees. Please be sure you understand the policies regarding cancelations and missed appointments, methods of payment, insurance reimbursement, and past due accounts. If you have any questions about anything, please ask me prior to signing this Agreement and Policy.
