Financial Responsibility Agreement-Self-Pay - LCOHPA

LCOHPA - FINANCIAL RESPONSIBILITY AGREEMENT SELF PAY SERVICES

"*" indicates required fields

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

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 43% 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.

Financial-Responsibility-Self-Pay

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.

Reset signature Signature locked. Reset to sign again
MM slash DD slash YYYY
Reset signature Signature locked. Reset to sign again
MM slash DD slash YYYY
Hidden
Hidden
MM slash DD slash YYYY