FINANCIAL AGREEMENT FORM
Psychological Services Center
University of Nevada, Reno
1) I understand actual cost of service provided is $85 per hour.
2) If I cannot pay $85, then I can apply for a fee adjustment, and I may be able to pay a sliding fee based on
income and number of children.
3) Any adjustment to the sliding fee must have the approval of the Director of the Psychological Service
Center. Further documentation may be required.
4) I agree to pay my fee at the end of each session if at all possible.
5) If I can't pay my entire fee at the end of each session, I understand billing procedures are available.
6) If billed for services, I agree to pay a reasonable amount regularly and promptly until the bill is paid. I will
work out an arrangement with my therapist.
7) If I have health insurance, I agree to do the following:
a) If my sliding fee is lower than the actual cost per hour ($85), I will assign the insurance payment to
the Psychological Service Center (PSC). I understand the PSC staff will send in the forms for me. I
understand that part or my entire sliding fee will be reimbursed to me if my fee payment and the
insurance payment exceeds $85 (actual cost of service) per hour. Any deductible expenses will be
included in this determination.
b) If my sliding fee is equal to the actual cost per hour ($85), I will not assign the insurance payment to
the PSC. However, I understand that the PSC staff will send in my insurance form for me. Any
deductible expenses must be paid before the above procedure is implemented.
c) I understand the usual practice is to send in insurance forms after a series of four sessions or
monthly. Normally, insurance forms are not sent after each session.
8) If I belong to a Health Maintenance Organization (HMO), I need to inform the therapist of this fact. The
therapist will discuss possible alternatives with me
9) If I am a full-time student at UNR, I need to inform the therapist of this fact. The therapist will discuss PSC
policies with me regarding my status as a full-time student.
_____________________________________________
Print Name of Client
_________________________
Amount
________________________________________
Signature of Client
_________________________
Date
_____________________________________________
Signature of Legally Authorized Representative
_________________________
Date
_____________________________________________
Signature of Therapist
_________________________
Date