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933.934.In return for a fee of $____ per session, I agree to provide counseling services for you. Sessions are 50 minutes in duration. It is impossible to guarantee any specific results regarding your counseling goals. However, I assure you that my services will be rendered in a professional manner consistent with accepted ethical standards.935.936.The fee for each session will be due and must be paid at the conclusion of each session. Cash or personal checks are acceptable forms for payment. I will provide you with a monthly receipt for all fees paid.937.938.In the event you will not be able to keep an appointment, you must notify me 24 hours in advance. If I do not receive such advance notice, you will be responsible for paying for the session you missed.939.940.If you are a member of a HMO, PPO, or some type of managed health care plan, Ican tell you if I am an authorized provider of services under that plan. If I am an authorized provider, services will be provided to you under the terms of that plan’s contract. Fees will be billed and collected according to the requirements of that plan. If I am not an authorizedprovider, you may still receive services from me for a fee, but your plan will not reimburse you for the cost of any of my services. Plans often will reimburse for only a limited number of visits per year. If you exceed that limit, you may still receive services from me, but your plan will not reimburse you for the cost of services that exceed their maximum number of visits.941.942.If you wish to seek reimbursement for my services from your health insurance company, I will be happy to complete any necessary forms related to your reimbursement provided by you or the insurance company. Since you will be paying each session for my services, any later reimbursement from the insurance company should be sent directly to you. Please do not assign any payments to me.943.944.Most health insurance companies will reimburse clients for my counseling services, but some will not. Those that do reimburse usually require that a standard amountbe paid by you before reimbursement is allowed and usually only a percentage of my fee is reimbursable. You should contact a company representative to determine whether your insurance company will reimburse you and the schedule of reimbursement that is used.945.946.Health insurance companies usually require that I diagnose your mental condition and indicate that you have an illness before they will agree to reimburse you. In the event a diagnosis is required, I will inform you of the diagnosis I plan to render before I submit it to the health insurance company.Theodore P. Remley, Jr., JD, PhD, LPC, LMFT ∞ Our Lady of Holy Cross College ∞ New Orleans, Louisiana ∞[email protected]∞Page 79
947.948.If you have any questions, feel free to ask. Please sign and date both copies of this form. You keep one and give the other copy to me.