Payment Contract for Psychotherapy and Assessment Services

I am committed to providing professional and responsible psychological services to my clients. In order to do so, I have established a set of policies which clarify payment options and obligations for my clients.

The Person Responsible for Payment of Account is required to sign this form, Payment Contract for Psychotherapy and Assessment Services, which explains the fees and collection policies. Your insurance policy, if any, is a contract between you and the insurance company; Dr. Bradlee provides services to you but is not a part of the contract between you and your insurance company.

As a service to you, this office will bill insurance companies and other third-party payers, but cannot guarantee such benefits or the amounts covered, and is not responsible for the collection of such payments. The Person Responsible for Payment of Account will be financially responsible for paying funds not paid by insurance companies or third-party payers after 60 days. Payments not received after 120 days are subject to collections. A 1% per month interest rate is charged for accounts over 60 days.

Insurance deductibles and co-payments are due at the time of service. The adult accompanying a minor (or guardian of the minor) is responsible for payments for the child at the time of service. If this is not possible, please let Dr. Bradlee know beforehand in order to work out a manageable payment arrangement.

All insurance benefits (from insurance company or third-party provider) should be assigned to Dr. Bradlee unless the Person Responsible for Payment of Account pays the entire balance each session.

An appointment for psychotherapy is a contract for professional services between the Person Responsible for Payment of Account and Dr. Bradlee. Missed appointments or cancellations with less than 24 hours prior notice will be charged at the rate typically paid by the insurance company, unless Dr. Bradlee deems that circumstances warrant an exception. Insurance companies, however, do not pay for missed appointments; therefore, they are exceptionally costly.

Any other questions regarding financial policies should be discussed with Dr. Bradlee

I have read, understand, and agree with the provisions of this Payment Contract.

_______________________________________________ ______________________

Signature of Person Responsible for Payment of Account                                                                          Date

_______________________________________________ ______________________

Signature of Co-responsible Party Date