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.