Common Contracts
2 similar Client Services Agreement contracts
Barbara Pherribo, LPCClient Services Agreement • September 28th, 2018
ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize payment, directly to Barbara Pherribo of insurance benefits for provided services otherwise payable to me. I agree that I am responsible for the total balance due on my account for services rendered by Barbara Pherribo, even though I may arrange for my health care plan to pay for part of it. I agree to allow Barbara Pherribo to use my credit card information that I provide for the purpose of paying off unpaid balances on my bill. It is my responsibility to inform Barbara Pherribo of my current address, phone number, and any change to my credit card information until my final balance is paid in full. Co-payments are due in full at the time service is rendered. Cash, Check, or credit card will be accepted. I understand that although I may arrange for my insurance to pay for the service that reimbursement by my insurance company to Barbara Pherribo will not be made unless my deductible is met in full. If my deductible is not met in full
Barbara Pherribo, LCMHCClient Services Agreement • September 28th, 2018
ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize payment, directly to Barbara Pherribo of insurance benefits for provided services otherwise payable to me. I agree that I am responsible for the total balance due on my account for services rendered by Barbara Pherribo, even though I may arrange for my health care plan to pay for part of it. I agree to allow Barbara Pherribo to use my credit card information that I provide for the purpose of paying off unpaid balances on my bill. It is my responsibility to inform Barbara Pherribo of my current address, phone number, and any change to my credit card information until my final balance is paid in full. Co-payments are due in full at the time service is rendered. Cash, Check, or credit card will be accepted. I understand that although I may arrange for my insurance to pay for the service that reimbursement by my insurance company to Barbara Pherribo will not be made unless my deductible is met in full. If my deductible is not met in full
