FEE AND PAYMENT AGREEMENTFee and Payment Agreement • November 17th, 2014
Based upon my family’s total yearly income of $ and my total family size of , my portion of the cost of services rendered by Le’Chris is .
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
Fee and Payment AgreementFee and Payment Agreement • May 24th, 2017
Jennifer Galea, MS RDN, will provide contracted nutrition services to the undersigned client. Services include nutritional evaluation, consultation and counseling.
Martial Arts Plus Acupuncture Equals Health, Inc. dba Acupuncture PlusFee and Payment Agreement • March 13th, 2022
Daniel Goodman MD (530)605-4557Fee and Payment Agreement • September 21st, 2020
Dr. Goodman has office hours from 10:00 a.m. to 4:00 p.m. Monday through Thursday. Dr. Goodman provides personalized patient care for each individual spending the time required to help assess, support, and optimize each persons individual anti-aging health issues. The time required varies for each person. Dr. Goodman’s pricing structure is based on the time he spends with each patient.
