Financial Responsibility Agreement-Self-Pay - LCOH

LCOH - FINANCIAL RESPONSIBILITY AGREEMENT SELF PAY SERVICES

  • 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.

  • MM slash DD slash YYYY
  • 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 54% 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.

  • 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.

  • BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THIS DOCUMENT

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Hidden
  • Hidden
    MM slash DD slash YYYY
  • Hidden
    :