• GRUNBLATT PSYCHOLOGY AND COUNSELING OFFICES, P.C.

    AGREEMENT TO PAY FOR MENTAL HEALTH SERVICES OUT-OF-POCKET RATHER THAN USE MY INSURANCE
  • I,   *   *, understand that psychotherapy for   *    *   *, or my *(specify name and relationship)   *   *   * , 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 $* directly by my insurance company and I would be responsible only for a copayment of $   *                         

  • The current charge of the psychotherapist for psychotherapy is $   *   per  *, 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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