Common Contracts
1 similar Financial Agreement contracts
Financial AgreementFinancial Agreement • August 21st, 2020
I, _ , agree to pay based on the service(s) provided, the established fees, and sliding scale rates as outlined below. I agree to pay the $60 no-show/late cancellation fee when I do not give my clinician at least a twenty-four (24) hour notice of my need to cancel an appointment. I understand that it is my responsibility to remember my appointment(s) and arrive on time. I agree to pay all charges related to penalties associated with unsuccessful payments.
