Appendix 9

Payment Contract for Services

Active clinic: [Company]

Use this contract to document the financial responsibilities of the client and legal guardian for services provided by the [Company]. By signing this agreement, the client and guardian acknowledge their financial obligations, including any copayments, coinsurance, deductibles, and non-covered services.

Client Information

Client name *

Date of birth *

Phone *

Email *

Address *

Parent or guardian (if applicable)

Effective date of services *

Purpose

This Payment Contract outlines the financial responsibilities of the client and legal guardian for services provided by the [Company]. By signing this agreement, you acknowledge understanding of your financial obligations.

Insurance Information (If Applicable)

Primary insurance company

Policy holder name

Policy number

Group number

Secondary insurance (if applicable)

The client or guardian authorizes the [Company] to verify benefits and submit claims on their behalf. Verification of benefits is not a guarantee of payment. The client or guardian is responsible for any portion not covered by insurance.

Client Financial Responsibility

The client or guardian agrees to be financially responsible for copayments, coinsurance, deductibles, non-covered services, services denied by insurance due to lack of eligibility or authorization, and services exceeding authorized hours if requested by the client. Payment is due at the time services are rendered unless otherwise arranged in writing.

Private Pay Rates (If Applicable)

Service type

Rate per hour or session

Payment method

Credit/Debit Card
Check
Cash
Electronic Transfer

Returned check fee (in dollars)

Missed Appointments and Late Cancellation Policy

Cancellation notice required (hours in advance)

Cancellation fee (in dollars)

Insurance does not typically cover missed appointment fees. The client or guardian is responsible for these charges.

Authorization and Assignment of Benefits

I authorize payment of insurance benefits directly to the [Company] for services provided. I authorize the release of necessary medical or treatment information to insurance companies for the purpose of claims processing.

Collection Policy

Days past due before collection actions begin

Accounts more than the indicated number of days past due may be subject to suspension of non-emergency services, referral to collections, and additional administrative fees. The client or guardian agrees to pay all reasonable costs of collection, including attorney fees if applicable.

Financial Hardship

If financial hardship occurs, the client or guardian may request review for financial assistance in accordance with the [Company]'s policy.

No Guarantee of Outcome

Payment is for professional services rendered. No guarantees are made regarding treatment outcomes.

Acknowledgment and Agreement

By signing below, I acknowledge that I have read and understand this Payment Contract for Services, that I accept financial responsibility for services provided, that I understand insurance verification does not guarantee payment, and that I agree to comply with the policies outlined above.

Signatures

Date *

Client Signature *

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Date

Parent or Guardian Signature (If Applicable)

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Date *

Authorized Agency Representative Signature *

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