Billing Policies

Please read and check each box, electronically sign and date below.

I (client/guarantor) understand that:

I am responsible to keep all scheduled appointments for myself or family members. Any requests for rescheduling or canceling an appointment requires a minimum of 24 hours notice for current patients and 48 hours notice for new patients. I understand that I must either call the office or contact Marilyn Pearlman directly. Request left via email are not acceptable.

A no-show or cancellation request in less than the above mentioned times, will be charged in full to my credit account at the private pay rate or the insurance contracted rate. My insurance company will not be billed.

I agree to keep a current charge card on file, and will take responsibility for informing the office should it change. Should I be under the ALMA billing service (Aetna, Cigna and Optum plans), I agree to be enrolled in their Auto Payment.

Payment is expected at the time of the appointment. Should I wish to submit an insurance claim for Out-of Network services, I will do so independently along with the prepared receipt. I will make this request known in advance.

I am responsible to keep all personal information up-to-date, which includes my address, email, phone numbers, insurance coverage, and credit card information.

Services provided by Marilyn Pearlman will not be used for any legal matters, nor for supportive documentation of Social Security benefits, disability, worker’s compensation or military review benefits, disability or worker’s compensation.

Client Consent

I give Marilyn Pearlman, LCSW my permission to communicate with my providers given below. She may also communicate with the listed family members with my knowledge and approval:

PROVIDERS

FAMILY MEMBERS

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SUBMIT FORM

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psychotherapy ADHD ADD Marriage Counseling Family Therapy Couple Therapy Trauma Stress Work LCSW Social Worker Phone Counseling PTSD Anxiety Depression Grief Dementia Addictions Bipolar Coaching Brain Mindfulness