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: Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Time Hours : Minutes AM PM AM/PM LCOHPA STAFF ONLY HiddenDate 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.) HiddenRevocation Date: MM slash DD slash YYYY HiddenTime Hours : Minutes AM PM AM/PM HiddenSignature of Financially Responsible Party: CAPTCHA