CREEKSIDE COUNSELING INC.

FINANCIAL AGREEMENT

Services provided by Creekside Counseling Inc. are based on an established fee schedule in cooperation with the major insurance carriers we do business with. Services rendered to Patients are based on identified treatment needs or in response to a request by the patient or patient’s parent/legal guardian. All charges for services rendered are the responsibility of the Patient or Patient's guarantor. When the Patient provides health insurance information, Creekside will bill that carrier on a regular basis as a courtesy to the Patient. Some health insurance carriers are not available for billing by Creekside and therefore will not be billed directly by this agency Creekside will however provide the patient with the necessary information to bill their carrier directly.

In the event that your health insurance carrier denies any claim submitted to them in your behalf in whole or part, you will be financially responsible for that amount. You are encouraged to contact your specific carrier(s) to identify, which of the following services may not be covered by your policy.

There are some services that have been previously established as NON-covered treatment activities by any insurance company. These are identified with an (.) preceding the service if you require or request these services, you are doing so with the knowledge that your insurance company will not be billed for those services. You will be billed directly for those services.

Evaluations @ $200.00 Intake/Admissions @ $135.00 Individual Counseling Session @ $90.00 pr hr. Group Counseling Session @ $40.00 pr. hr Urine Analysis Testing @ $3500 per specimen (not covered by all insurance companies)

Based on some contracts, different rates may be charged for any or all of the above services instead of the rated identified above.

Education Classes (MI.P. or D.U.I.I. Information) @ $250.00 ·

Letters Requested ~ $25.00 minimum ·

Fax @,$5.00 minimum ·

Phone/Medical consultations @ $4000 (over 15 min.) ·

Photocopying ~ $5.00-$35.00 ·

Court Appearance @ $500.00 per day in advance

DOWNPAYMENT: $50.00 Visa, Master Card, Check or Cash is requested at the time of admission. This will be applied directly to your portion of the bill (co-payments, or on your percentage of your policy 800/0-20% etc) In the event you leave treatment prior to this amount being used, any remaining amount will be refunded directly to you with the last accounting statement.