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Sliding Scale Fee Agreement Template

This document outlines a sliding scale fee structure for counseling sessions based on annual household income. Fees range from $75 per 55-minute session for households earning less than $30,000 annually to $150 per session for households earning over $90,000. The document also addresses insurance billing options and requires clients to sign agreeing to the payment terms.

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chizoba enwereji
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176 views1 page

Sliding Scale Fee Agreement Template

This document outlines a sliding scale fee structure for counseling sessions based on annual household income. Fees range from $75 per 55-minute session for households earning less than $30,000 annually to $150 per session for households earning over $90,000. The document also addresses insurance billing options and requires clients to sign agreeing to the payment terms.

Uploaded by

chizoba enwereji
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Sample Sliding Scale

Annual Household Income Cost per session


(55 minutes)
< $30,000 $75
$30,001 - $40,000 $85
$40,001 - $50,000 $95
$50,001 - $70,000 $105
$70,001 - $90,000 $125
$90,001 + $150

By signing below I agree to the above fee schedule and understand payment (cash, check, Visa, MasterCard, etc) is due in full at the time of the session.

* I also agree to pay a fee of $___ plus the amount for the check for any returned checks.

* I understand the following regarding the use of insurance or slide fee scale:

IN NETWORK INSURANCE

If I have insurance coverage with a company that __________, is In-Network with, I will:

___ Bill my insurance using an appropriate diagnostic code

___ Pay the fee listed above in full

OUT OF NETWORK INSURANCE

I have out-of network insurance with ______________________, I will:

___ Bill my insurance using an appropriate diagnostic code. I will be responsible for the full session fee amount. I will seek reimbursement from my
insurance for the difference between what my insurance covers and the full amount listed above.

___ I will not use my insurance and pay in cash, using the sliding fee scale above.

The agreed upon fee per 55-minute session is _____________________.

____________________________________________________ __________________
Client Date

____________________________________________________ __________________
Parent/Guardian Date

____________________________________________________ __________________
Therapist Date

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