Benna Z. Sherman, Ph.D.
Licensed Psychologist
479
Jumpers Hole Road, Suite 304B
Severna
Park,
MD 21146
Phone: 410-544-9564 Fax: 410-647-9174
email:
bzsherman@comcast.net
Practice
Policies and Fee Agreement for Professional Services
Office hours are 9 a.m. to 4 p.m.,
Monday through Friday. Voice mail is
available 24 hours a day. Phone calls
are generally for administrative matters, such as scheduling appointments. Therapeutic matters are to be reserved for
therapy sessions. There is no charge for
brief, administrative phone calls.
The charge for initial sessions is $200
for 50-60 minutes. The fee for therapy
is $140 per 45-50 minutes. Full fees are
to be paid at time of service. For your
convenience, you may pay by cash, check, Visa, MasterCard, Discover, or
American Express.
Full
charge is made for any sessions missed or canceled with less than 24 hours
(business day) notice.
This means, for example, that a 2:30 Tuesday appointment
must be cancelled by 2:30 on Monday. Monday
appointments must be cancelled by Friday, since weekends are not business
hours. Similarly, appointments following
holidays must be cancelled by the preceding business day.
Cancellations must be made in person
or by phone/voicemail. Email is not
adequate unless it is well in advance AND you have received a confirmation
email from me.
Voice mail-- (410)544-9564-- is available at all times and automatically records
the date and time of incoming calls.
In the
event of inclement weather, there will be an outgoing message on the voicemail
by 7 a.m. to tell you if the office is closed.
Please call to confirm the status of your appointment.
I do not participate with any
insurance company or other third party payor.
I maintain NO relationships with insurance companies and do not either
bill them or accept payment from them. If you request it, at the end of each month an itemized
invoice (“Superbill”) will be provided to you that you can submit to your
insurance company for reimbursement. If
treatment plans are required and you wish to submit one, we will complete it
together during your session time and you will be responsible for submitting
it. It is your responsibility to keep
track of when an authorization expires and when a summary is due.
The
person accepting financial responsibility for professional services will be
responsible for any costs involved in the event that a court, your attorney, or
other legal entity with whose orders I must comply requires my services or my
records. The financially responsible
party will be expected to pay for all of my professional time, including
preparation and transportation costs, even if my participation is compelled by
another party. I charge $280 per hour
for preparation and/or attendance at any legal proceeding.
If
a minimum negotiated payment is not made for two months on overdue balances,
your overdue balance will be applied in full to a credit card (below). Alternately, the account may be turned over
for collection or to Small Claims Court, and the person accepting financial
responsibility for professional services will be responsible for any expenses
incurred to collect overdue balances.
Regardless of how you intend to pay for
sessions, please provide a current credit card number. It will only be used at your request or if
you default on payment of your account.
__________________________ ________ _____________
Card
# Expires Name on card
____________
3 digit verification code on back of card, on signature strip
I
have read and I understand the conditions of this agreement and agree to abide
by these conditions. I have received a
copy of this agreement.
___________________________ _______________
signature
date
(9/09)
