AGREEMENT TO PAY FOR PSYCHOTHERAPY NOT COVERED BY HEALTH INSURANCE

GRUNBLATT PSYCHOLOGY AND COUNSELING OFFICES, P.C.

AGREEMENT TO PAY FOR PSYCHOTHERAPY NOT COVERED BY HEALTH INSURANCE
I, First Name Last Name, understand that certain psychotherapeutic services for (check one) myself my child First Name Last Name, or myfamily member (specify name and relationship) First Name Last Name Type a label, has not been (will not be, in the opinion of the psychotherapist,) authorized for payment (has been denied coverage) under my mental health managed care plan (state name of plan) Type a label because my health plan considers (would consider) such psychotherapeutic service to be optional or not medically necessary.
I understand that this psychotherapeutic service is anticipated to involve (describe non-covered treatment, including nature, goals, frequency and length of treatment and fee per session):
I have discussed with the psychotherapist the purpose, risks, benefits and alternatives to the service, and that the psychotherapist believes that the service will be beneficial. I am seeking this service voluntarily because I too believe the service will be helpful even if not deemed medically necessary. Because my mental health managed care pan (has not) (will not, in the opinion of the psychotherapist) authorize payment, I understand and agree that the psychotherapist will not submit claims for this service on my behalf.
I choose to have the above-described treatment furnished by First Name Last Name (the psychotherapist) even though my mental health managed care plan (will not, in the opinion of the psychotherapist,) or (does not pay for it.) As a result, I take full responsibility for payment of all fees to the psychotherapist in connection with the above psychotherapeutic service.

This agreement will be enforceable in the courts of New York State.
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GRUNBLATT PSYCHOLOGY AND COUNSELING OFFICES, P.C.