Financial Responsibility Agreement-Self-Pay - Telephone Visits Telephone Visits - FINANCIAL RESPONSIBILITY AGREEMENT SELF PAY SERVICES "*" indicates required fields Patient Name* First Last Patient DOB:* MM slash DD slash YYYY MR#:Date* MM slash DD slash YYYY Financially Responsible Party (if other than patient):Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 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) related to telephone visits. I understand that payment for services is due at the time services are rendered unless special arrangements are made in advance. I understand this service is completely self/private pay and is unbillable to my insurance coverage. As such an itemized statement is not available. The charges listed below are not a full listing of charges but represent the most utilized by provider type. The discount for clinician 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. Other Services Other other: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:*Date* MM slash DD slash YYYY Printed Name of Patient or Legal Guardian:*Relationship of Legal Guardian to Patient:Signature of Financially Responsible Party:*Date MM slash DD slash YYYY This field is hidden when viewing the formLCOHPA Witness Signature:This field is hidden when viewing the formWitness Date: MM slash DD slash YYYY CAPTCHA