Part II · Appendix 9
Payment Contract for Services
Financial obligations and payment terms between client and clinic.
The Payment Contract documents the financial responsibilities of the client and, when applicable, the legal guardian for services provided by [Company]. It is signed at intake, before services begin, and updated whenever financial arrangements change.
The Payment Contract for Services form on the right captures the client’s contact and identifying information, the effective date of services, any primary and secondary insurance details, private-pay rates and payment method (when applicable), the cancellation-notice window and any returned-check or late-cancellation fees, the past-due threshold that triggers collection actions, and the full acknowledgement covering insurance verification, financial responsibility, assignment of benefits, collections, and the no-guarantee-of-outcome clause.
The contract is signed by the client (and the parent or guardian when applicable) and countersigned by an authorized [Company] representative. The signed contract is filed in the recipient’s clinical and billing record.