Fee Schedule Client Name: ________________________________________________________________ Clinician Name: ________________________________________________________________ Type of Service Dollar Amount Individual Therapy $ 60.00 (30 Minutes) 90832 Individual Therapy $ 90.00 (45 Minutes) 90834 Individual Therapy $ 120.00 (60 Minutes) 90837 Family Therapy (60 $ 120.00 Minutes) 90847 Group Therapy (60 $ 60.00 Minutes) 90853 My signature below acknowledges that I understand the above Fee Schedule. I also understand that this rate may be adjusted according to my insurance company’s allowed amount. If there are any problems with your insurance, please contact us. Client Signature: _________________________________Date: __________ Parent/Guardian Signature: ________________________Date: __________ Clinician Signature: _______________________________Date: __________
Fee Schedule Client Name: ________________________________________________________________ Clinician Name: ________________________________________________________________ Type of Service Dollar Amount Individual Therapy (30 Minutes) 90832 $ 60.00 Individual Therapy (45 Minutes) 90834 $ 90.00 Individual Therapy (60 Minutes) 90837 $ 120.00 Family Therapy (60 Minutes) 90847 $ 120.00 Group Therapy (60 Minutes) 90853 $ 60.00 My signature below acknowledges that I understand the above Fee Schedule. I also understand that this rate may be adjusted according to my insurance company’s allowed amount. If there are any problems with your insurance, please contact us. Client Signature: _________________________________Date: __________ Parent/Guardian Signature: ________________________Date: __________ Clinician Signature: _______________________________Date: __________
NS-Fee-Schedule.docx