AGENCY
Client Financial Responsibility & Authorization Form
Thank you for choosing our agency as your Service Provider. We are committed to providing you with the highest quality of care. We ask that you read and sign this form to acknowledge your understanding of our Client Financial policies.
Client Financial Responsibilities
• The Client (or Client's guardian) is ultimately responsible for the payment for services and care.
Clients are responsible for payment of copays, coinsurance, deductibles and all other procedures or services not covered by their insurance plan
• $0 Copay for grant funding participants. $0 Copay for self-pay participants. Insurance Copays are due at the time of service.
Coinsurance deductibles and non-covered items are due 30 days from receipt of billing.
Clients may incur, and are responsible for payment of additional charges, if applicable. These charges may include: Charge for returned checks - $30.00.

By my signature below, I hereby authorize the assignment of financial benefits directly to AGENCY. and any associated healthcare entities for service rendered as allowed under standard third-party contracts. I understand that I am financially responsible for charges not covered by this assignment.

Client Acknowledgement and Authorization

• We respect client confidentiality and only release personal health information about you in accordance with State and Federal law. The attached notice describes our policies related to the use of the records of your care and how you may get access to this information. Please review this policy carefully. By my signature below, I acknowledge that I have received and read the privacy notice provided by AGENCY. to release medical and other information acquired in the course of my services to the necessary insurance companies, third party payors, and or other physicians or healthcare entities to participate in my care.

* Prohibition Against Re-Disclosure: This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of information to criminal! Investigate or prosecute an alcohol or drug abuse client. "* If other than the client's signature, a copy of legal paperwork verifying the client's personal representative MUST accompany the request unless otherwise on file with the provider (e.g, court appointed guardian, durable power of attorney for healthcare, grandparent power of attorney). Exception: Parent signing for client under the age of eighteen and the County agency holding custody.