Yumi Hiraga, Ph.D.
www.arboretumpsych.com
dr.yumihiraga@gmail.com
400 E Pine St, Suite 220
Seattle, WA 98122
(206) 729-2829 x3
Financial Agreement and Credit Card Authorization Form
Today’s date: ___/____/____
Client Name: ________________________________
Payment for psychological services by health insurance is variable and can be confusing. Dr. Hiraga is
in-network for most, but not all, of the major Regence plans, and is out-of-network for all other insurance
plans. I understand that I am responsible for understanding the mental health benefits of my plan (for
example, in-network versus out-of-network coverage, whether parent-only sessions are a covered benefit,
etc.) and for obtaining the necessary authorizations and referrals. I agree that my financial responsibilities
include the following: [Please initial each section and sign at bottom of page].
______Therapy and Consultation – Regence. For in-network coverage under a Regence insurance plan,
payment of all copays and co-insurance fees in full.
______Psychological and Comprehensive Learning Evaluations – Regence. Psychological and
comprehensive learning evaluations may not be covered by insurance plans for several reasons
including diagnostic exclusion and medical necessity deemed unnecessary. Services that are not
covered as an in-network benefit by my health insurance plan will be billed at $250 per hour for
the evaluation.
______For out-of-network insurance coverage, payment for each session in full at the time of service, at
the following rates:
$260 for an initial intake session
$185 per 45 minute therapy session (up to 52 minutes)
$200 for sessions that exceed 52 minutes (up to 60 minutes)
$140 per 25 minute session (up to 37 minutes)
$250 per hour for psychological and comprehensive learning assessments
$230 per hour for other services such as letters in which clinical information is discussed,
communication with other professionals, and services provided by telephone
Hourly rates are higher for preparation of reports to be used for legal purposes and for attendance
at legal proceedings.
______Payment of $185 for missed appointments ($140 per 25 minute session) without 48-hour
cancellation (the 48 hours does not include weekends), unless both of us agree that the missed
appointment was due to circumstances beyond my control.
______Finance charge of 1.5% for accounts not paid in full on a monthly basis
______Service charge of $25 for returned checks.
______Patient choice to not use insurance. Although services are covered by my insurance plan, I
voluntarily choose to pay Dr. Hiraga her full fee for these services out of pocket.
I (cardholder name), ____________________________________________ authorize credit card
payments for services rendered by Yumi Hiraga, Ph.D.
Credit Card Type:
 Visa
 MasterCard
Name on Credit Card: ______________________________________________
Relationship to client: ______________________________________________
Credit Card Number (MC/VISA only): _________________________________
Expiration date: _______________________
Security # on Back of Card: ____________________
Billing Address: _______________________________________________________
_____________________________ Zip: _____________________
Please initial:
______ Charges for each office visit and phone calls are billed on your credit card according to the fee
schedule presented above.
______ Missed appointments and late cancellations will be charged on your credit card according to the
policies and fees specified above.
______ For in-network services through Regence, your credit card will be charged for copays and
coinsurance fees after claims are processed.
______If I am in-network with your insurance plan but provide a service that is not covered by your
plan, your credit card will be charged according to the fee schedule above.
___________________________________________________
Signature of Client or Legal Guardian
Date