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  • Home
  • Services
    • Psychotherapy
    • Psychological Assessment
    • Public Programs
    • Group Therapy
  • Clinicians and Staff
    • Administration
    • Clinicians – Bethesda
    • Clinicians – Fairfax
    • Clinicians – Alexandria
  • Clients
    • Fees
    • Client Forms
    • Therapy Portal
    • Feedback
  • Blog
  • FAQ’s
  • Resources
    • Subscribe Newsletter
    • Recommended Books
    • Useful Links
  • Contact
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Third Party Payor Agreement

Home/Third Party Payor Agreement
Third Party Payor AgreementIWSS2022-03-07T12:06:27+00:00
If you are a third party who agrees to pay for the psychological services rendered to a client of Alpha Omega Clinic, please complete and submit the information below. Please note that Alpha Omega Clinic will not initiate third party billing without the written consent of the client and Alpha Omega Clinic will not disclose confidential information to the payor without the client's prior authorization.

I/We elect to pay the amount indicated below by our initials (choose one):

Amount Pay
OR

I understand that any balance remaining after the third-party payment is received will become the responsibility of the client.

Checkbox

By signing below, I/We agree to pay the amount as indicated above for the client to receive psychological services at Alpha Omega Clinic for the term of this agreement. If the client does not show for a scheduled appointment, the client (not the third party) will be responsible for the cancellation fee.

DD slash MM slash YYYY

Note: This agreement expires one year from the date signed or upon completion of the number of sessions listed above, whichever comes first.

In the event Alpha Omega Clinic needs to contact me regarding my payments or to mail an invoice, below is my billing and contact information:

Address(Required)

Table of Services & Standard Fees

Service code (CPT Code) Description Fee for Service (Provisional License or Under Supervision/LPC, LCPC, LCSW, LMFT/Licensed Psychologist)
90791 Initial Diagnostic Evaluation $190/205/220
90832 Individual Psychotherapy 30 minutes $113/123/133
90834 Individual Psychotherapy 45 minutes (This is the standard session length) $170/185/200
90837 Individual Psychotherapy 60 minutes (This fee is the hourly rate & used for all prorated calculations as indicated) $227/247/267
+99354 Prolonged Session (add-on code for additional 30 min) $113/123/133
90845 Psychoanalysis $100
90846-47 Family Psychotherapy 50 min $190/205/220
90853 Group Psychotherapy, 75 min $85
96130-96133, 96136-96139 Psychological and Neuropsychological Testing $200 per hour
98966-98968 Telephone Assessment & Management Prorated based on the amount of time spent at hourly rate
98970-98972 Online Digital Evaluation & Mgt (Responding to Email & Text Messages) Prorated based on the amount of time spent at hourly rate
Cancellation Fee We require a 48-Hour Cancellation Fee The client is responsible for the fee of the appointment missed
Documents Prorated based on the amount of time spent at hourly rate
Court Appearances Prorated with a minimum of a half day based on the amount of time spent at hourly rate
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Bethesda, Maryland7007 Bradley Boulevard, Bethesda, MD 20817

Ellicott City, Maryland5086 Dorsey Hall Dr, Ste 206, Ellicott City MD 21042

Catholic psychologists and counselors serving Maryland and Virginia Logoaoclinic

Fairfax, Virginia9677 Main Street, Fairfax, VA 22031

Alexandria, Virginia6408 Grovedale Drive Ste 204, Alexandria, VA 22310

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Fairfax, Virginia9677 Main Street, Fairfax, VA 22031

Alexandria, Virginia6408 Grovedale Drive Ste 204, Alexandria, VA 22310

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