Financially Responsible Party. Initial Here The parent or guardian who signs this agreement will be considered the responsible party and will receive all billing statements and letters. Any alternative financial arrangements, including court-ordered financial arrangements, must be worked out between the parents or guardian of the children outside of this agreement.
Financially Responsible Party. If this or a separate PHW, LLC Financial Responsibility Statement is signed by another person, on my account, then that co-signature remains in effect until canceled in writing. Cancellation in writing shall become effective the date after receipt and shall apply only to those services and charges thereafter incurred. By signing as a financially responsible party, I hereby guarantee the full and prompt payment to PHW of all indebtedness of patient to PHW, whether now existing or hereafter created (the “Indebtedness”); and I further agree to pay all expenses, legal or otherwise, incurred by PHW in collecting the Indebtedness, in enforcing this guaranty, or in protecting its rights under this guaranty or under any other document evidencing or securing any of the Indebtedness. This guaranty shall be a continuing, absolute and unconditional guaranty, and shall remain in force and effect until any and all said Indebtedness shall be fully paid. There shall be no obligation on the part of PHW at any time to first exhaust its remedies against me, any other party, or any other rights before enforcing the obligations of the financially responsible party. If the patient is under the age of eighteen (18) a parent or legal guardian must sign this agreement and the responsible party must be currently employed. I understand and agree to all the above information regarding my financial responsibility to Psychiatric, Health & Wellness, LLC. All questions have been answered to my satisfaction. Print Full Name of Financially Responsible Party Signature of Financially Responsible Party Date
