Financial Responsibility Agreement-Self-Pay - LCOH LCOH - FINANCIAL RESPONSIBILITY AGREEMENT SELF PAY SERVICES "*" indicates required fields The Lindner Center of HOPE (LCOH) appreciates the confidence you have shown in choosing us to provide health care services to you or a patient for whom you have responsibility. Our patient and family-centered treatment philosophy requires that we openly communicate our policies and expectations about payment for our services before treatment is initiated. Please take a moment to familiarize yourself with these policies. In the event that my insurance will not cover the services provided or if I choose not to use insurance, I acknowledge that I am financially responsible for all charges associated with health care services provided by LCOH to me (or the patient named above). I understand that payment for services is due at the time services are rendered unless special arrangements are made in advance. Professional fees are billed separately. Patient Name* First Last Patient DOB* MM slash DD slash YYYY MR# Date* MM slash DD slash YYYY INPATIENT SERVICES: I acknowledge that I am financially responsible for all charges associated with health care services provided by LCOH to me (or the patient named above). I understand that payment for services is due at the time services are rendered unless special arrangements are made in advance. I understand that I will be responsible for the total billed hospital charges less a discount based on amounts generally billed to insurance and Medicare (discount is currently 50% of billed charges for patients residing in Ohio and 25% for non-Ohio residents). I understand that I am responsible for payment and agree to set up payment arrangements with the financial counselor prior to discharge for any balance due.Initials I acknowledge that I (or the patient named above) do not have health insurance coverage. I understand that LCOH will extend financial assistance to uninsured or underinsured patients for inpatient services who meet certain criteria. The financial counselors can assist with this process. OR I request that whether or not I (or the patient named above) have insurance that may provide coverage for mental health services, LCOH may not bill my insurance company for privacy reasons. I understand that LCOH will extend financial assistance to uninsured or underinsured patients for inpatient services who meet certain criteria and that this assistance will not be considered for patients who have opted not to use active/eligible insurance or government program coverage. Initials OUTPATIENT HOSPITAL SERVICES: In the event that my insurance will not cover the services below or if I choose not to use insurance, I acknowledge that I am financially responsible for all charges associated with health care services provided by LCOH to me (or the patient named above). I understand that payment for services is due at the time services are rendered unless special arrangements are made in advance. Self Pay discounts are factored into the prices listed below and there will be no additional discount on the bundled rates disclosed below.Initials Intensive Outpatient Treatment (IOP): $370 Per Day Intensive Outpatient Treatment (IOP) Eating Disorders: $400 Per Day Transcranial Magnetic Stimulation (TMS): $345 Per individual Session -or- $3,450 for a series 10 TMS sessions Transcranial Magnetic Stimulation (TMS) Maintenance: $275 per session Electroconvulsive Therapy (ECT): $800 ECT Treatment only: Anesthesia and other professional services associated with ECT will be billed separately. Partial Hospitalization Program (PHP): $540 Per day Partial Hospitalization Program (PHP) Eating Disorders self-pay rate:$695 per day Therapeutic Injection: $10 Per Injection $175 Ketamine Injection BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THIS DOCUMENTSignature of Patient*Date* MM slash DD slash YYYY Signature of Financially Responsible Party*Date* MM slash DD slash YYYY Relationship of Financially Responsible Party to Patient* HiddenLCOH Witness Signature: HiddenWitness Date: MM slash DD slash YYYY HiddenTime Hours : Minutes AM PM AM/PM CAPTCHA