William F Martin
1300 West Belmont
Chicago, Il 60657
312-409-0632
Service and Fee Agreement Fee Policy, Confidentiality Statement, and Consent for Services
Name:
Address:
Phone: home cell work
Email address:
Payment Policies
- Payment is due at the beginning of each session.
- I charge for any writing, email correspondence/reading and telephone calls at $25 per 15 minutes.
- All appointments not cancelled within 24 hours are charged full fee.
- My fees range between $75 and $140 and depend on various insurance reimbursement schedules and client’s ability to pay.
- I am in-network with the Blue Cross Blue Shield PPO, Cigna PPO, and Medicare ONLY. The client fee for both these insurance programs is $75, so typically $37.50, plus any deductible is the co-payment for clients.
- Any other PPO insurance program will provide a reimbursement to you, but you will need to contact them for specific details.
- You will also be responsible to submit this insurance claim, as I am a solo provider and can not take responsibility to submit claims on your behalf.
- I always try to work with everyone who requests my services and will make an effort to do so, despite a client’s ability to pay. If someone can pay full fee, great. If not, I am willing to negotiate a manageable fee.
- I require 24 hours advance notification if you are not able to keep a scheduled appointment, including group therapy sessions. This notice permits me to offer that time to someone else.
- If you have given 24 hours notice, you will not be charged for the appointment. However, if you break your appointment and do not call my office at 312-409-0632 (no other number will work) 24 hours in advance of your appointment, you will be charged the full fee for your session.
- I understand that there may be occasional emergencies when you will not be able to keep your appointment and also will not be able to notify us within 24 hours, for example illnesses and/or accidents where no charge will be made for the early cancellation.
- Occasionally, it is necessary for a session to be held elsewhere, ex. hospital, school, court, other agency or center . My out-of-office fee is $140 per hour, from my office door back to my office door. Thus, a one-hour session of any type and travel time of 30 minutes each way would result in a charge of two hours.
- Brief telephone calls in which you advise me of a schedule change or ask for a specific piece of information are not charged. If the duration of the call is less than five minutes, you will not be charged. If the situation requires telephone consultation that exceeds five minutes, the fee for such service will be pro-rated at your normal fee.
- If your need is more urgent and complex and it cannot be postponed until a scheduled appointment, an immediate emergency appointment will be arranged and billed at usual fee.
- If, with your permission, I contact other people on your behalf—such as family members, teachers, or other health care professionals—and consult with them in person or by telephone, then the above fees for scheduled in-office and out-of-office sessions, as well as telephone contacts, will apply.
Confidentiality
All of our sessions will be confidential unless there is any concern of harm to yourself or others. This includes the possibility of a child under the age of 18 being abused, physically, sexually or physically. In the event that there is a risk of harm to someone, it is my legal and ethical responsibility to take immediate action to protect that person. This action could include calling 911 or having a person hospitalized for their own or some other person’s protection.
Fee Agreement
- By signing below I am indicating that I have read the above statements on fees and payment policies.
- I have discussed these conditions with William Martin, LCSW and have had the opportunity to ask any questions. My questions have been answered to my satisfaction.
- I understand and agree to meet my financial responsibilities in receiving treatment and services in this practice setting.
- I understand that any unpaid balance in my account may be sent to a collections agency after 90 days of failure to pay.
- I further agree and permit the use of a credit card I submit to be used for the payment of co-payments, deductibles or other balances in my account.
Credit Card on File
To cover expenses for copayments or fees for cancelled sessions, I ask you togive me a credit card number to keep on file.
Credit card type:
Name on Card:
CC #:
Expiration Date:
Client name (please print):
Signature:
Date:
