Payment Agreement

Thank you for choosing Awaken Mental Wellness for care as your Provider. Please read and sign this form to acknowledge and agree to accept financial responsibility for services rendered by Provider to Client. 

Practice Contact Person: Michelle Wakeley 

Practice Name: Awaken Mental Wellness 

Practice Address: 726 E. Park Ave. #185 

Practice City, State, and ZIP: Fairmont, WV 26554 

Practice Phone Number: (304) 534-9321 

Practice Email: info@awakenmentalwellness.com 

Location of Service: Telehealth 

NPI: 1629465786 

TIN: 92-1914943 

• Client understands Provider is NOT an In-Network provider for any insurance plan, including commercial plans, EAPs, Medicaid, and Medicare. Client attests the Provider did not encourage, initiate, coerce, persuade, imply, or otherwise cause Client to make this decision to pay out-of-pocket, verbally or otherwise; this decision is my own for my own reasons. 

• Client understands they will receive a Good Faith Estimate that shows the costs of items and services that are reasonably expected for their health care needs. 

• Client understands if they intend to use Out-of-Network benefits they will need to inform the Provider prior to service delivery, make payment at the time of service, request a Superbill from Provider, and submit the Superbill to their insurance company as the Provider does not offer courtesy billing. Client understands a Superbill is not a guarantee of reimbursement as it is at the discretion of the insurance provider. Client understands Superbills require sharing HPI, including demographic information and diagnosis/diagnoses. 

• Client agrees to review the Payment Agreement with Provider bi-annually to re-assess the established payment arrangement, or sooner by request if financial circumstances significantly change, and report any relevant changes in ability to afford services. Client understands that if they leave and return to therapy for any reason a new Payment Agreement will need to be signed. Client acknowledges and agrees that they are ultimately responsible for the payment to Provider for any and all services rendered by Provider to Client in connection to Provider providing care to Client. 

• Client understands it is expected that payment per session be paid by or at the time of service, unless other arrangements have been made in advance between Client and Provider. 

• The Provider reserves the right to cancel the upcoming session and all future sessions if payment is not made. Client gives permission to the Provider to charge the full fee of the service for all appointments missed by the Client, including late cancellations that occur within 48 hours prior to the scheduled appointment time and failure to arrive for scheduled appointments within 15 minutes following the scheduled appointment time. 

• Client agrees to provide a valid credit card number, with expiration date, for payment of therapy sessions, or other fees, that will be kept on file within the Electronic Health Record System (Simple Practice) which is HIPAA and PCI compliant. Client declares that they are the authorized user for the card being placed on file and agrees to update information regarding any changes to the credit card information. 

• Client understands that they may be charged for other services directly related to their treatment, including extended phone calls, consultation to other professionals, report writing, etc. that are rendered on Client's behalf. All these services are charged at a prorated amount based on the agreed upon session rate in 15 minute increments. The exception is Court-Related Activities, as outlined in the Practice Policies. 

• Client acknowledges that Provider may recommend frequency and duration of treatment based on Client's assessed needs. Client understands they are not required to attend therapy for any length of time and they are able to terminate therapy at any time. Client understands Provider may terminate treatment if Client requires a higher level of care, Client requires an alternative service not offered by Provider, or due to non-payment from Client to Provider of agreed upon rates and fees. In the event Provider terminates treatment Client will receive a list of referral options. 

Last updated: Feb 14, 2025

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Client name: ________________________________________________________________________

Client Address: ______________________________________________________________________

Client City, State, and ZIP: _____________________________________________________________

Client Email Address: _________________________________________________________________

Client Phone Number: ________________________________________________________________

Client Date of Birth: __________________________________________________________________

Today's Date: _______________________________________________________________________

Agreed upon rate per session: __________________

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Client’s Name: _______________________________________________________________  Client’s Date of Birth:  _____________________

Client’s Signature: __________________________________________________________  Today’s Date: ______________________

(IF THE CLIENT HAD ASSISTANCE REVIEWING AND COMPLETING THIS FORM, PLEASE INCLUDE:)

Name of Person Assisting Client: __________________________________________________

Relationship to the Client: ________________________________________________________

Phone Number for Person Assisting Client: __________________________________________

Signature of Person Assisting Client: _______________________________________________

Please use the contact information listed below to return the completed form.