Third-Party Payer Form

Informed Consent to Assume Payment Responsibility for Psychotherapy

  • I,
  • agree to pay for psychotherapy services and other clinical services for
  • according to the fee agreement between the therapist and the patient.
  • I understand the following terms apply to this agreement:
    - Payment will be made as follows; (check one):
  • If "Other", please specify:
  • - The fee for psychotherapy, consultation, letter or report writing or other clinical services is $200 per 50-minute session unless otherwise specified. For more details, see previous informed consent.

    - Please inform Dr. Bear Korngold ahead of time or as soon as you know if there are changes in your ability or willingness to pay.

    - Services will be terminated if timely payment is not made as agreed to by this consent.

    - Consent to assume financial responsibility for these services does not entitle the third- party payer access to confidential information unless agreed in writing otherwise by the named above patient.

    - Upon your request and upon obtaining patient’s written permission, if appropriate, you will be provided with a bill, which is suitable for presenting to your insurance carrier for possible reimbursement. Not all conditions are reimbursable.

    - This agreement supplements previous informed consents.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

If you would rather print out, sign and have this form brought to the first appointment, please download document here: Third-Party Payer (PDF)