Financial
Good Faith Estimate for Mental Health Services (Forms Template)

This form can be used by mental health providers to full the required good faith estimates of expected charges. This requirement goes into effect in January 2022.  A Good Faith Estimate must be provided within 3 business days. Information regarding services must be furnished within 1 business day of scheduling a service to be provided in 3 business days and within 3 business days of scheduling a service to be provided in at least 10 business days.  We recommend using the Psychology Forms Filler to individualize this form for your practice.   (2021, practice management, financial, forms)

Insurance Payer Appeals Letter (Timely Filing)

This letter can be used by therapists to appeal an insurance payer denial when a claim has been denied due to timely filing. (0720)

Ethical Payment Practices for Therapists

This document outlines ways therapists can adhere to sound ethical practices regarding fees. (0720)

Authorization for Recurring Credit Card Charges

This form can be used to obtain permission to keep a client’s credit card number on file and charge it as fees are incurred.

Invoice for Psychotherapy Services

This form can be given to clients to submit to their insurance companies for reimbursement.

Superbill

A Superbill is an itemized form used by healthcare providers to reflect rendered services. A Superbill is the main data source for creation of healthcare claim, which is
submitted to payers to insurance companies or other payers.

Receipt For Therapeutic Services

This form can be given to a client as a receipt for services. There is one receipt for monthly services and one for individual sessions.

Sliding Scale Fee Agreement

This form can be modified to state a therapist’s sliding scale schedule and to obtain a signed agreement regarding the terms of a reduced fee.

Principles of Ethical Payment & Billing for Therapist

This fact sheet describes general ethical guidelines for billing and payment for therapeutic services. It includes links to the specific guidelines of various professional organizations. PDF

Letter of Termination to Client for Nonpayment

This letter can be used as a template when a client must be terminated for nonpayment of agreed-upon fees.