• I agree to make payment at the conclusion of my session.
• I agree to pay a minimum of $25.00 or my known co-pay at the time of service. I am aware that medical co-payments may differ from mental health co-payments.
• I agree that I am responsible for the entire fee regardless of my insurance and that I will pay any unpaid balance in full within 60 days of the date of service.
• I understand that appointments not cancelled 24 hours in advance, as well as "no-shows," will result in a $35.00 charge which cannot be billed to my insurance carrier. I also understand that additional fees may be billed for services such as phone calls more than 10 minutes in length, written reports and other professional services.
• Patients whose accounts have had no payment activity for 60 days will not be seen again until financial arrangements have been made.
• Patients will not be scheduled if their unpaid balance exceeds $500.00.

Finance Charges

• I agree to pay a $20.00 fee for returned checks.
• I agree to pay 21% interest on past due balances.
• I agree to pay a collection fee of 30% on my balance in the event that my account is delinquent and turned over to a collection agency for action.
• I agree to pay reasonable attorney fees and court costs in the event that it is necessary to commence legal action to collect this bill.
• I agree to submit myself to mediation or arbitration and pay the costs of such should any portion of this bill or the provider's services be disputed.

Authorization

• I authorize the release of any medical, psychiatric and/or alcohol and substance abuse information needed by my insurer or employer to process fee-for-service claims.
• I authorize payment of both basic and major medical insurance benefits to Paul M Dymock, LCSW.
• I am, by my signature, requesting that an account be opened in my name. Because this action involves the extension of credit to me, I consent to inquiries regarding my credit history with the Credit Bureau and recognize that my credit history established with this office will also be reported.
• I understand that Paul M Dymock, LCSW will keep my information confidential unless I give written consent for its release. I do, however, understand that Paul M Dymock, LCSW, is required by law to report clear and present danger to human life and any form of child abuse.
• I also understand that it may be necessary for Paul M Dymock, LCSW, to furnish information to a court of law if a subpoena is issued (in cases such as child custody, accidents, injuries, and divorce).
• I acknowledge that, even though many people benefit from receiving psychological treatment, there is no guarantee that I or my family members will be helped.
• I certify, by signing on behalf of a minor, that I am his/her legal guardian and have the legal right to give approval for said minor's evaluation and treatment as well as the release of his/her information.
• I understand the risks and responsibilities noted above and agree to the inherent conditions stated or implied.