AGREEMENT TO PAY FOR MENTAL HEALTH SERVICES OUT-OF-POCKET RATHER THAN USE INSURANCE

GRUNBLATT PSYCHOLOGY AND COUNSELING OFFICES, P.C.

AGREEMENT TO PAY FOR MENTAL HEALTH SERVICES OUT-OF-POCKET RATHER THAN USE MY INSURANCE
I, First Name* Last Name*, understand that psychotherapy formyself, my child (specify name)* First Name* Last Name*, or my family member*(specify name and relationship) First Name* Last Name* Type a label* , is a covered service under my health insurance and will if I so choose to use my insurance benefit as payment for psychotherapy, then the psychotherapist would be paid $Type a label* directly by my insurance company and I would be responsible only for a copayment of $ *
Nevertheless, I wish not to use my insurance company benefit and instead to pay the psychotherapy for the requested service completely out of picket. The reason I choose not to use my insurance benefit is:*
The current charge of the psychotherapist for psychotherapy is $ * per Type a label*, and is subject to change by the psychotherapist. I personally take responsibility for payment in full of all fees to the psychotherapist in connection with the above services. I understand and agree that I will not submit the bills of the psychotherapist to my insurance company in order to seek any reimbursement.
I understand that once I enter into this Agreement with the psychotherapist, I cannot retroactively change my decision with regard to services already rendered by the psychotherapist.

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