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 billed separately.

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  • 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 and that upon admission a $7,500 deposit is due. I understand that I may be requested to make additional deposits and agree to set up payment arrangements with the financial counselor prior to discharge for any remaining balance due.

  • RESIDENTIAL SERVICES

    I acknowledge that Sibcy and Williams House services are not in-network services for any insurance plan regardless of whether Lindner Center of HOPE is an in-network provider and that LCOH may or may not have the ability to assist me in billing my insurance. However, I request that whether or not I (or the patient named above) have insurance that may provide coverage for mental health services, LCOH may not bill my insurance company for privacy reasons.

  • 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.

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

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