Behavioral Health (BH) Financial Responsibility Agreement BEHAVIORAL HEALTH (BH) FINANCIAL RESPONSIBILITY AGREEMENT - LCOHPA "*" indicates required fields Patient Name:* First Last DOB:* MM slash DD slash YYYY MR#:Financial Responsibility Party Name:*Billing Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number:*FINANCIAL RESPONSIBILITY AGREEMENT FOR SERVICES: Lindner Center of Hope Professional Associates (LCOHPA) 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. I acknowledge that the patient has signed the required release forms requesting that all billing statements are to be sent to the person named as financially responsible below. I agree that I am financially responsible for all charges associated with health care services provided by LCOHPA for 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 further understand that I have the right to revoke this responsibility upon written notification and signature of revocation. THE UNDERSIGNED HAS READ AND UNDERSTANDS THE ABOVE.Printed Name of Financially Responsible Party:*Relationship to Patient:*Signature of Financially Responsible Party:Date MM slash DD slash YYYY Time Hours : Minutes AM PM AM/PM LCOHPA STAFF ONLY This field is hidden when viewing the formDate of receipt of signed Release of Information by patient MM slash DD slash YYYY (Please note that the signed Release of Information is only good for 6 months.) This field is hidden when viewing the formRevocation Date: MM slash DD slash YYYY This field is hidden when viewing the formTime Hours : Minutes AM PM AM/PM This field is hidden when viewing the formSignature of Financially Responsible Party:CAPTCHA