Client Financial Responsibility AgreementClient Financial Responsibility Agreement • March 2nd, 2018
We appreciate the confidence you have shown in choosing us to provide for your health care needs. The service you have elected to participate in implies a financial responsibility on your part. The responsibility obligates you to ensure payment of any charges not covered by your insurer, payment of any deductibles, co-pays and co-insurances as determined by your contract with your insurance carrier.
Client Financial Responsibility AgreementClient Financial Responsibility Agreement • August 18th, 2020
Thank you for choosing the Auburn Davis Center for DBT as your mental health care provider. We are honored by your choice and are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our client financial policies. The client (or client’s guardian if a minor) is ultimately responsible for the payment for his/her treatment and care. We are pleased to assist you by billing for providers that we have a relationship with, however, we are not an in-network provider for most insurance companies. Client’s are required to provide us with the most correct and updated information about their insurance and will be responsible for any charges incurred if information is not correct or updated.
Client Financial Responsibility AgreementClient Financial Responsibility Agreement • February 1st, 2022
We are honored by your choice and are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our client financial policies. The client (or client’s guardian if a minor) is ultimately responsible for the payment for his/her treatment and care. We are pleased to assist you by billing for providers that we have a relationship with, however, we are not an in-network provider for most insurance companies. Clients are required to provide us with the most correct and updated information about their insurance and will be responsible for any charges incurred if information is not correct or updated.
Client Financial Responsibility AgreementClient Financial Responsibility Agreement • August 12th, 2024
The following document explains The Wellness Centre’s payment policy and financial responsibility for all clients (including minors). It aims to minimize any misunderstanding about payment for services.
Client Financial Responsibility AgreementClient Financial Responsibility Agreement • September 9th, 2021
Thank you for choosing the Auburn Davis Center for DBT as your mental health care provider. We are honored by your choice and are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our client financial policies.
CASA Speech Therapy, LLC CLIENT FINANCIAL RESPONSIBILITY AGREEMENTClient Financial Responsibility Agreement • January 25th, 2019
Thank you for choosing CASA Speech Therapy, LLC (“CASA”) as your speech therapy and/or occupational therapy provider. This Agreement sets forth your financial obligations for all of the services your child receives from CASA Speech Therapy, LLC including the services provided today and in the future. If you do not understand any of the items discussed in this Agreement, we will explain those items to you.
