FINANCIAL AGREEMENT FOR PSYCHOTHERAPY SERVICES
Mindful Sasquatch PLLC
Rendering Provider: Ryan Q Patterson, MA, LMHC
Service Address:
14090 Fryelands Blvd, Suite 316
Monroe, WA 98272
Mailing Address:
PO Box 2354
Snohomish, WA 98291-2354
Phone: 425-205-9332
NPI: 1538425632
Effective Date: July 16, 2026
SCOPE OF SERVICES
Psychotherapy and counseling services include professional interactions between clinician and client, including but not limited to:
• In-person sessions
• Telehealth sessions (when separately authorized)
• Clinically relevant telephone or electronic communication
Standard psychotherapy sessions are 50–55 minutes, unless otherwise scheduled in advance.
STANDARD RATE
The standard self-pay rate for a 50–55 minute psychotherapy session is:
$165.00 per session
This rate represents the full fee for services and is used as the basis for billing, including when insurance coverage applies. For services covered under an in-network insurance agreement, the contracted rate governs the amount payable, and your responsibility is limited to the cost-sharing amounts (such as copayments, coinsurance, and deductibles) determined by your plan.
Rate protection: the standard rate in effect at the time you sign this agreement will remain your rate for the duration of continuous treatment. Any future rate increases apply only to clients who begin services after the effective date of the increase.
CLIENT FINANCIAL RESPONSIBILITY
By acknowledging this agreement, you understand and agree that:
• You are financially responsible for all psychotherapy services provided by Mindful Sasquatch PLLC, regardless of insurance, EAP participation, or third-party payment, except amounts Mindful Sasquatch PLLC is contractually required to adjust or write off under an in-network insurance agreement.
• Insurance benefits are determined by your individual policy and are a contract between you and your insurer; they are not guaranteed by the provider.
• You are responsible for understanding and meeting applicable deductibles, copayments, coinsurance, coverage limits, and authorization requirements.
• Any portion of fees not paid by insurance, for any reason, remains your responsibility, subject to the in-network adjustment exception described above.
This acknowledgement applies to all services rendered unless otherwise agreed to in writing.
INSURANCE BILLING
If you choose to use insurance benefits:
• Mindful Sasquatch PLLC will submit claims to your insurance carrier as a courtesy, when applicable.
• Payment responsibility remains with you if claims are denied, benefits are exhausted, services are deemed non-covered, or claims are paid at a reduced rate, subject to the in-network adjustment exception described above.
• At the beginning of each calendar year, clients may be charged the full standard rate (or applicable contracted rate) until deductibles are met and insurance coverage is confirmed.
• If insurance payments are sent directly to you, you agree to promptly forward those payments to Mindful Sasquatch PLLC.
OUT-OF-NETWORK SERVICES
For out-of-network services, you are responsible for the full standard rate at the time of service. Any reimbursement received from your insurance will be applied upon receipt.
PHONE SESSIONS AND TELEPHONE CONTACT
Brief telephone check-ins of up to twenty (20) minutes are offered at no charge. Administrative calls, such as scheduling, are also not billed.
Phone sessions — including sessions that begin as telehealth and are completed by telephone due to technology difficulties — are billed at the standard session rate (or applicable contracted rate). Insurance coverage for phone sessions varies by insurer and is not guaranteed; amounts not covered remain your responsibility.
PAYMENT AUTHORIZATION
You agree to maintain a current credit or debit card on file and authorize Mindful Sasquatch PLLC to charge:
• session fees,
• late cancellation or missed appointment fees,
• and other charges consistent with this agreement and the Practice Policies.
Timing of charges: fees may be charged to your card on file on or after the date of service, including automatic charges processed overnight following a session. When insurance is billed, your cost-sharing amount may not be charged until your insurer has processed the claim, which can take several weeks or longer; as a result, charges may appear on your card some time after the date of service.
MISSED APPOINTMENTS AND LATE CANCELLATIONS
Sessions not cancelled or rescheduled at least 24 hours in advance are subject to the full session fee.
Insurance companies and EAPs do not reimburse for missed or late-cancelled appointments; therefore, these fees are your responsibility.
Details regarding emergency cancellations are outlined in the Practice Policies.
REFUNDS AND OVERPAYMENTS
Occasionally an overpayment may occur — for example, when a copayment or coinsurance amount changes after a deductible has been met, or when an insurer adjusts a previously processed claim. I make reasonable efforts to notify you promptly when an overpayment is identified.
Overpayments, including those resulting from insurance adjustments, duplicate payments, or billing corrections, will — at your preference — be refunded to you or credited toward future services, within thirty (30) days of identification.
CHANGES IN INSURANCE OR FINANCIAL STATUS
You agree to notify Mindful Sasquatch PLLC promptly of any changes in insurance coverage or financial circumstances that may affect billing.
AUTHORIZATION TO RELEASE INFORMATION FOR BILLING
You authorize the release of necessary clinical and billing information to insurance carriers or third-party payers for the purpose of claims processing.
You also authorize insurance benefits, when applicable, to be paid directly to Mindful Sasquatch PLLC.
GOOD FAITH ESTIMATE (NO SURPRISES ACT)
If you are uninsured or choose not to use insurance, you are entitled to receive a written Good Faith Estimate of expected charges under the federal No Surprises Act.
A Good Faith Estimate will be provided within the timeframes required by law: no later than one (1) business day after scheduling when the service is scheduled at least three (3) business days in advance; no later than three (3) business days after scheduling when the service is scheduled at least ten (10) business days in advance; and no later than three (3) business days after any request, whether or not a service has been scheduled.
The Good Faith Estimate:
• is based on information known at the time it is provided,
• is not a contract, and
• does not guarantee final costs if treatment needs change.
If you receive a bill that is four hundred dollars ($400) or more above your Good Faith Estimate, you have the right to dispute the charges through the U.S. Department of Health and Human Services patient-provider dispute resolution process. The dispute must be initiated within one hundred twenty (120) calendar days of the date on the bill.
More information is available at www.cms.gov/nosurprises/consumers or by calling 1-800-985-3059.
ACKNOWLEDGEMENT
By electronically acknowledging this document, you confirm that you have read, understood, and agree to the Financial Agreement for Psychotherapy Services of Mindful Sasquatch PLLC.
Version date 7/16/2026