Client Financial Agreement:Client Financial Agreement • July 31st, 2019
First Name Middle Name Last Name SS# DOB Gender Physical Address City State Zip Code Mailing Address City State Zip Code Employer Name Employer Address Occupation Home Phone Work Phone Cell Phone Email Address Emergency Contact Name Emergency Contact Number
West Bergen Mental Healthcare Client Financial AgreementClient Financial Agreement • May 8th, 2013
West Bergen Mental Healthcare is a private, not‐for‐profit organization. The Agency is dependent upon fees which are generated by the cost of treatment. There are some essential things to keep in mind regarding billing, payments and insurance reimbursements.
Client Financial Agreement FormClient Financial Agreement • September 21st, 2012
During your initial appointment we ask for you to put a valid credit card number on file. This policy gives consent for OnTrack Counseling Lehigh Valley consent to bill your card $45 dollars if you fail to give 24 hour notice in canceling an appointment.
Client Financial AgreementClient Financial Agreement • August 27th, 2014
Note: Fees are subject to change. Clients utilizing the sliding fee scale are required to notify the ZVMHC Business Office of any change in income or number of people in household, which may affect the client percentage.
CLIENT FINANCAL AGREEMENT & OFFICE POLOCIESClient Financial Agreement • March 15th, 2024
David Phillips is a private Core Engergetics & Reiki Practitioner who is committed to providing you with the best possible care. In order to achieve this goal, your understanding and acceptance of the policies and financial agreement below is necessary. Please thoroughly review the following and sign where indicated. These policies and fees are subject to change without prior written notice. You will be informed about the updated policies and fees when a request is made for these services. Furthermore, as we cannot always anticipate every need and situation that arises, some policies and fees are not included and will be addressed on a case by case basis.
if different from client)Client Financial Agreement • December 10th, 2018
Client Financial AgreementClient Financial Agreement • April 11th, 2017
In order to reduce confusion and misunderstanding between our clients and the practice, we have adopted the following financial policy. If you have any questions, please discuss them with your provider. We are dedi- cated to providing the best possible care to you and regard your complete understanding of your financial responsibilities as an essential element of your care and treatment.
A Family Works, Counseling PLLCClient Financial Agreement • March 1st, 2017
AFWC will make every attempt to comply with your insurance company’s requests. Since policies and benefits differ among employers and individuals, we are unable to know the specifics of your policy. Your insurance company informs all participants that ultimately it is your responsibility to verify your benefits and coverage prior to receiving any services.
