Financial Responsibility Agreement-Self-Pay - LCOHPA

LCOHPA - FINANCIAL RESPONSIBILITY AGREEMENT SELF PAY SERVICES

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Patient Name:*

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Patient DOB:*

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Date*

Financially Responsible Party (if other than patient):

Address*

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Phone Number:*

PATIENT FINANCIAL RESPONSIBILITY AGREEMENT FOR SERVICES NOT COVERED BY INSURANCE:

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 I am financially responsible for all charges associated with health care services provided by LCOHPA to me (or the patient named below) not covered by insurance. I understand that payment for services is due at the time services are rendered unless special arrangements are made in advance.

The charges listed below are not a full listing of charges but represent the most utilized by provider type. The discount for physician services calculated under the AGB guidelines is 41% for patients that reside in Ohio. For patients residing outside Ohio the self-pay discount is 25%. Such discount will show up on our patient statement as applicable.

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THE UNDERSIGNED HAS READ AND UNDERSTANDS THE ABOVE. I am the patient or am legally authorized to sign this document. I have read and understand this Consent for Self-Pay Services.

Signature of Patient or Legal Guardian:*

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Relationship of Legal Guardian to Patient:

Signature of Financially Responsible Party:*

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LCOHPA Witness Signature:

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Financial Responsibility Agreement-Self-Pay - LCOHPA

LCOHPA - FINANCIAL RESPONSIBILITY AGREEMENT SELF PAY SERVICES

THE UNDERSIGNED HAS READ AND UNDERSTANDS THE ABOVE. I am the patient or am legally authorized to sign this document. I have read and understand this Consent for Self-Pay Services.