Third Party Payor Agreement

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.

Payor Name(Required)

Patient Name(Required)

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

Amount Pay

The full amount accrued for psychological services rendered to the individual listed above.

A partial amount accrued for psychological services rendered to the individual listed above, not to exceed:

Amount

Total Course During

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

Card Name

Credit Card(Required)

Expiration (MM/YY)(Required)

CVV(Required)

ZIP Code(Required)

Checkbox

Check here if you are a diocese, parish, school or religious organization who has received pre-approval to receive a monthly invoice. By selecting this option, you agree not to carry a balance of more than 6 unpaid sessions or services may be withheld from the client until the balance is paid.

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.

Signature(Required)

Date(Required)

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:

Name(Required)

Phone(Required)

Organization (if applicable):

Client ID# (if applicable):

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

Phone

This field is for validation purposes and should be left unchanged.

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

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:

Table of Services & Standard Fees

Title

Bethesda, Maryland7007 Bradley Boulevard, Bethesda, MD 20817

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

Fairfax, Virginia9677 Main Street, Fairfax, VA 22031

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

Fairfax, Virginia9677 Main Street, Fairfax, VA 22031

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