Practice management
Agreement of Financial Responsibility
Agreement of Financial Responsibility
Establishing a clear financial frame is fundamental to maintaining therapeutic boundaries. Ambiguity regarding fees, insurance, and extra-sessional services can lead to client confusion and complicate the clinical work. This directive is designed for use during intake to address these logistical matters transparently from the outset, preventing future misunderstandings that could detract from treatment. It provides a formal structure for obtaining informed financial consent.
This instrument facilitates a methodical review of your practice policies, prompting the client to deliberately consider each component of the service agreement. This approach confirms their understanding and acceptance of their responsibilities in a way a standard signature line cannot. By formalizing this conversation at the beginning of the professional relationship, you effectively separate administrative requirements from the therapeutic process, preserving the integrity of the clinical space.
Agreement of Financial Responsibility
Please review and initial each item to confirm your understanding and agreement.
| Policy | Initial to Acknowledge |
|---|---|
| Charges are based on a clinical hour, defined as 45-50 minutes. | |
| You will be charged the usual hourly fee for any appointment missed or cancelled with less than 24 hours’ notice. This fee is not covered by insurance. | |
| Services outside of scheduled sessions (e.g., phone calls, record reviews, consultations) are your responsibility and will be charged on a quarter-hour basis. | |
| You are fully responsible for all charges associated with custody cases and court-related services. | |
| By initialing, you authorize payment of insurance benefits to this office and the release of necessary information to process claims. | |
| If your insurance denies claims due to a lack of prior authorization, you are responsible for the full fee for those sessions. | |
| You are financially responsible for all copayments, deductibles, and charges not covered by insurance. Payment is required at the time of service. | |
| For minor clients, the person scheduling the appointment is responsible for ensuring the copayment is collected at each visit. | |
| By initialing, you authorize the release of your name, address, telephone number, and outstanding balance for any necessary collection matters. |
By signing this agreement, you acknowledge your understanding and acceptance of the office’s financial policies and procedures.
Signature: _________________________________
Date: _________________
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