ADDITIONAL CHARGES:  There will be a charge for phone calls or preparation of insurance claims if they exceed 15 minutes and will be billed at the half-hour rate of $70.  Occasionally, scheduled session time will be devoted to filling out insurance forms in order to minimize costs, and to keep you fully informed of what is disclosed to your insurance company, this cost is not covered by insurance companies. 

When psychological tests are administered, or if reports of any kind are prepared for another party or you, there will be an additional charge.  If you are not sure if this applies to you, please ask your therapist.

Phone sessions will be billed at the standard therapy session rate in half-hour increments when they exceed 15 minutes.  There will be a $33 charge for returned checks.  A finance charge of 2% per month will be calculated on all balances over 90 days due. 

MISSED & CANCELLED APPOINTMENTS:  Since scheduling of an appointment involves the reservation of time specifically for you, missed appointments and cancellations less than 24 hours prior to the scheduled appointment will result in a charge for that time.  Our phone is answered 24 hours per day and a message is sufficient notice during times when the office is closed.

FAILURE TO PAY YOUR BILL:  Financial hardships may occur to any of us.  These hardships should be discussed with your therapist as soon as they develop, so that necessary changes in your payment agreement may possibly be made. Non-payment may result in collection efforts or legal action.  If an account is sent to collection, you will also be held financially responsible for all collection fees assessed to our practice. 

Some insurance carriers select a panel of providers to deliver therapy services and my not reimburse for services from other professionals outside their network.  It is recommended you contact your insurance representative for pre-approval to confirm your coverage.  We are a fee-for-service practice, thus, insurance reimbursements should be sent directly to you.

CONFIDENTIALITY:  Information revealed in your session is confidential and will not be released to others without your permission.  Several legally required exceptions to confidentiality include situations of potential harm to oneself or others, incidents of child abuse (Ohio has a mandatory child abuse reporting law), incidents of elderly or dependent abuse and situations where a court may order records.

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PAYMENT AGREEMENT

As a client of Palmentera & Associates, Inc. I understand that I am
financially responsible for professional services by me or those for whom
I am responsible.  It is my intention to carry out my financial responsibility
to Palmentera & Associates, Inc. in the following manner: 

___________ I will pay for all professional services at the time they are offered.  I will file my own insurance claims and request that Palmentera & Associates, Inc. provide me with statements and/or receipts.  (Note:  All court-related services fall into this category.)

___________ Other (please specify)/ Comments:

 I understand Palmentera & Associates, Inc. service, fee and payment policies and agree to comply with these conditions.  I understand all
charges for services rendered are my responsibility.

Name of Client:____________________________________________   

Date of Birth:______________________________________________

Signature of Client/Responsible Party:

_________________________________________________________ 

Date:___________________________

Signature of Therapist: 

_________________________________________________________   

Date:____________________________

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