Guarantor Agreement


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  • The Guarantor is financially responsible for services provided to the Patient by NYC Psychology PC/Center for Anxiety LLC (hereinafter “NYCP/CFA”). The following terms are mutually agreed upon:
    • NYCP/CFA does not accept insurance and is a private pay facility.
    • Guarantor will unconditionally cover all financial obligations of the Patient to NYCP/CFA.
    • Guarantor will promptly pay for all amounts billed in connection with all services provided to the Patient, upon receipt.
    • If payment is not received within ten (10) days following billing, NYCP/CFA may terminate all patient services and cancel all scheduled appointments.
    • If payment is not received within thirty (30) days following billing, a late fee of 1% of the balance owing will be charged. If payment is not received within sixty (60) days, accounts will be considered in default and turned over to collections.
    • Guarantor agrees to pay all costs incurred by NYCP/CFA in the event of a late payment or default, including reasonable attorney fees associated with collections.
    • Guarantor acknowledges the NYCP/CFA cancellation policy: If Patient needs to cancel or reschedule an appointment, Patient must contact our office at least one (1) business day in advance. Payment will be due in full for sessions that are missed without provision of one (1) business days’ notice.
    • Guarantor will be charged a $100 fee for any check that is returned unpaid, whether or not it can be resubmitted for payment.
    • The terms of this agreement are ongoing and cannot be voided due to changes in legal circumstance, health insurance, or termination of services with NYCP/CFA when there is any remaining balance, without consent by both parties (Guarantor and NYCP/CFA) in writing. There are no understandings, representations, or agreements, between the Guarantor and NYCP/CFA relating to payment, which are not contained in this agreement. Guarantor must inform NYCP/CFA of any contact information or address changes.
    • This agreement shall be construed and enforced according to the laws of the within state the treatment is being provided. Guarantor consents to the jurisdiction of the state the treatment is provided in the event of legal proceedings.
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