Common Contracts
1 similar Financial Agreement contracts
Financial AgreementFinancial Agreement • March 23rd, 2020
The patient or responsible party signing this form hereby certifies that the information provided is complete and correct, and authorizes Four County Mental Health Center, Inc. to send information for billing as requested by payment sources. This information may include, if specifically requested, copies of the admission evaluation, treatment plans, discharge summary, clinical progress notes, and any other records produced by this agency. This authorization will expire upon completion of processing of my insurance claim and any subsequent requests or audits by the payment source, unless expressly revoked by me at an earlier date. I further understand that revoking my consent may result in my being responsible for payment of the claim and the above payment source(s) not being used.
