Fee Schedule and Financial Policy   

OFFICE:   978 413-9118  

FAX: 978-610-2213  

BILLING: 978 264-4851                                                                

Clinical Services (Covered by Insurance)

Initial Evaluation (CPT 90791) 45-50 min $185.00

Psychotherapy, 45 min (CPT 90834)      $140.00             

Psychotherapy 30 min (CPT 90832)          $80.00

Psychotherapy, 60 min (CPT 90837)      $180.00    

Family/Couples Therapy (CPT 90847)    $155.00

* Not all insurances will cover this service

Consultative Services (Not Covered by Insurance)

Written Reports by request   $160.00  Per hourly rate  

Consultation (phone, school, agency, another therapist)  $160 per hour or per time used    

Coaching Services $100.00  Per hourly rate - please see Coaching contract

Private Pay Services (Self Pay)    

Services for Extended sessions

Initial Evaluation   90791   50-60 Min     $200.00           

45 min Individual Meeting   $140.00

45 min Couples/Family Meeting   $155.00

60 min Individual Meeting   $180.00

60 min Couples/Family Meeting    $195.00

75 Min Individual Meeting   $230.00

75 min  Couples/Family Meeting   $250.00

90 Min Individual Meeting   $280.00            

90 min Couples/Family Meeting   $300.00

No Show/Late Cancels (Not Covered by Insurance)

Failure to keep a scheduled appointment without 24 hour advance notice will result in a charge equal to your regular rate being due from you.  These may not be billed to insurance company or paid by flexible spending or HAS accounts but are your responsibility.

Payment Policy:

• Payment is expected prior to or at the time of service for all self-pay clients.

• Insurance deductibles, and copays are due at the time of service. Payments can be made by: cash in the exact amount , check made payable to: Frederique C Begin, LICSW, or via credit card agreements either monthly or one time.

Health Insurance:

• Please check with your insurer to determine policy limits, copayments, deductibles and whether your insurance for mental health is a “preferred provider panel” in which I participate. Your insurance benefit relationship is a “direct contract” between you and your insurer. You are responsible for knowing the number of sessions your policy covers, if pre-authorization is required, and at what level I am covered under your insurance.

I have read and agree to Frederique C Begin, LICSW’s Financial Policies.  Please note that Fee Schedule Increases may occur based on increased costs but you would be notified in advance of any change.

________________________________________________________________________

 Patient or responsible party Date

Privacy Practices Acknowledgement (form available online):

I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

Name_________________________    Signature ______________________________  Date____________