I wish to contract with the Mood Treatment Center for legal services including testimony, consultation with my attorney, and/or preparation of documents. I understand that these services are billed on an hourly basis and that insurance does not cover these charges.
I agree to pay for them according to the rate schedule below:
Physician (MD) $300
Nurse Practitioner (NP, PA) $175
Psychologist (PhD, PsyD) $200
Masters Level Therapist (MA, MS, LPC, MSW, LMFT, LPA, LCAS) $150
In order to initiate these services, I will also pay a retainer equal to one hour of work. This retainer will serve as a deposit and will be credited towards my account after the service is provided. If no service is provided, the retainer will be refunded to me. (Choose type of retainer below).
In signing below, I agree to these terms and also give Mood Treatment Center permission to communicate with my legal representatives.
I understand that I have a right to revoke this authorization at any time.
I understand that if I revoke this authorization, I must do so in writing and present my written revocation to Mood Treatment Center.
I understand that the revocation will not apply to information that has already been released in response to this authorization.
I understand that this authorization for disclosure is voluntary and that I need not sign this form to ensure healthcare treatment.