NO SURPRISES ACT FORM Private Insurance: We are so pleased you have continued to work with us and we work hard to provide you with the best treatment that we can. Typically, at the start of the new year most private insurances ‘reset,’ which means you may have to pay the full amount for therapy services until you meet your deductible. Prior to your visit, we are trying to check benefits, but please understand that this is a best guest and your insurance may come back with a different payment amount after billing. Based on that, please contact our offices to find out exactly how much you'll be paying. Self-Pay: We have different rates based on the therapist you see: Dr. C Rogers-Larke- $100/session; $125/intake LPC-A - $80/session LPC- $90/session Mr. Liam Burnside (LISW-CP)- $90/session; $100/intake Medicaid: Medicaid eligibility will be checked monthly, if it lapses or you have a primary insurance (typically private insurance) that has not been disclosed and Medicaid provides us with a denial, you will be responsible for paying for those sessions. Payment: Any payment is due at time of service. We can pay in office (by cash, check, credit card), or via square after our office manager sends you an invoice. If payment is not received, prior to the next appointment, that appointment will be cancelled. If you accrue a bill, and have not made arrangements with us to pay off the bill, it may be referred to a collector when it has been 3 months.Email Address(Required) Signature of client/parentPrint Name Date MM slash DD slash YYYY Client Name First Last Signature of therapistPrint Name Date MM slash DD slash YYYY