Behavioral Health (BH) Financial Responsibility Agreement

BEHAVIORAL HEALTH (BH) FINANCIAL RESPONSIBILITY AGREEMENT - LCOHPA

"*" indicates required fields

Patient Name:*
MM slash DD slash YYYY
Billing Address:*

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.

MM slash DD slash YYYY
Time
:
This field is hidden when viewing the form
MM slash DD slash YYYY
This field is hidden when viewing the form
MM slash DD slash YYYY
This field is hidden when viewing the form
Time
:
This field is hidden when viewing the form