Assignment of Benefits and Payment Agreement

  • Date Format: MM slash DD slash YYYY
  • 1. I understand that I/we will be financially responsible for and agree to CenterPoint Counseling and Consulting for all services rendered for the above named client. Treatment fees for self-pay are $85.00 for individual sessions, $95.00 for couples and family sessions. Couples therapy agreement is set for 3 self-pay sessions and then insurance, if available, maybe used for further sessions. Administrative fees for needed reports or summaries will be charged at the individual hourly rate. Phone calls exceeding 10 minutes will be charged at the rate of 2.00 per minute beginning at a flat fee of $25.00.
  • 2. I assert that my/our method of payment will be:
  • (check one) (Couples therapy check both if using insurance after 3 sessions) If I/we are paying through an insurance plan, all information is correctly provided below. If additional or incorrect insurance payment is determined, I/we will be responsible for the full balance owed to CenterPoint Counseling and Consulting. All co-pays for insurance plans will be collected at time of service. Associated plan deductibles apply and will be invoiced accordingly for direct client payment.
  • 3. Signature on File: "I request that payment of authorized Medicare and Medicaid Services or other named private insurance program benefit organization listed above be made either to me or on my behalf to the name of provider of service and (or) supplier for any services furnished to me by that provider of service and (or) supplier. I understand that a mental health diagnosis may be needed for third party, insurance reimbursement. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services or to any other named private insurer listed above and its agents any information needed to determine these benefits or the benefits payable for related service."
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
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