Financial Agreement

(if different from client)
We are committed to providing quality care to our patients, including transparent billing practices. Please review our financial policy below, initial next to each statement and sign your agreement at the bottom. This is required prior to beginning treatment.
Payment method All applicable insurance co-pays must be paid in full at the time of service. We require patients to provide a credit or debit card to be stored with our HIPAA-compliant, secure electronic payment vendor. For your protection, only the last 4 digits of your card number will display in our system. You will receive an electronic receipt reflecting your payments.

Please be sure to inform us immediately of any changes to your credit/debit card information. If the card on file is declined for any reason, future services will be suspended until we receive updated payment information.

Insurance Billing

Insurance billing Please understand that we must receive current and accurate insurance information in order to confirm active coverage and benefits prior to your first visit. We expect that you will notify our office of any changes to your name, address, insurance coverage, or other information required to bill your services in a timely manner. In addition, you are responsible for understanding your health insurance policy details, including: mental health benefits available, in- or out-of-network status, exclusions on your policy, and authorization or referral requirements. Failure to do so could result in the denial of your claims, and full financial responsibility for all billed charges. If you disagree with the way a claim is processed by your insurance carrier, you are responsible for disputing this directly with your plan.

For patients without insurance coverage, we offer sliding fee scale rates for our services. We can review these specific service costs with you upon request. Payment will be due at the time of service.

Balance Settlement

Balance settlement Please understand that your account balance is the amount that your insurance carrier has determined to be the patient responsibility for your services. When we are notified by your plan regarding the portion that you will owe, the credit or debit card on file will be charged up to a maximum of $200 as an initial payment on this balance. You will then receive a statement for any additional amount that you owe.

Please call our office to make a payment arrangement within 30 days of your statement date. We offer a payment plan option that will automatically charge your credit/debit card each month on a day of your choosing.

Please note: We reserve the right to suspend or terminate services for accounts more than 60 days in arrears. Collection activity will be initiated on accounts more than 90 days past due.

Missed Visits

Missed visits Missed visits, or those canceled with less than two (2) hours advanced notice will result in a $75.00 fee. Appointments may be canceled by responding to the voice/text reminder that you receive, or by contacting our office directly to cancel. Your clinician will then be informed to review and issue this fee if appropriate. Missed visit fees will be charged to the credit/debit card on file. Please be advised that missing up to three (3) appointments within a 12 month period could result in dismissal from our clinic.


for agreed upon charges (co-pays, outstanding balances, missed visits). I understand that Aspen Counseling & Consulting is using a third party electronic payment vendor to securely store my payment information. No credit/debit card information will be stored in my electronic health record or on the physical premises.

Credit/Debit Card Authorization Form

Please complete all fields. This information will be used to create a customer profile with our electronic payment vendor to store your card information. Once complete, this form will be destroyed.