1258 High Street, Eugene, OR 97401
Phone 541-342-8437 | Fax 541-242-2999
Client Financial Responsibility - Fee Agreement
(Behavioral Health Services - Oregon)
Client Name: Date of Birth:
Responsible Party (if different):
General Information
• I am responsible for contacting my insurance company to verify coverage and benefits.
• I understand my coverage depends on eligibility, medical necessity, and authorization by my insurance company.
• I understand that my insurance coverage is a contract between me and my insurance company, and CFD does not guarantee payment of claims.
• I agree to provide accurate insurance information and notify CFD of any changes in my coverage.
• If I have secondary insurance, I agree to provide all necessary information so CFD can submit claims.
• If CFD is out-of-network, I may be responsible for the full cost of services.
• If my insurance coverage ends for any reason, I may be responsible for the full cost of treatment.
• Services may be paused if my balance remains unpaid in accordance with CFD policy.
• I authorize CFD to bill my insurance (commercial, Medicare, or Medicaid) for covered services and to provide information to the payer(s) that is necessary to complete the billing process.
Medicare / Commercial Insurance
• I am responsible for copayments, coinsurance, and deductibles as determined by my plan.
• I am responsible for paying for services that are not covered or are denied by my insurance company. This includes services provided outside of my plan’s network (unless prohibited by law) and services that are denied after they are provided. I will not be billed more than the contracted rate between CFD and my insurance company when In-Network.
• Cancellation fees and no-show charges are not covered by insurance, and I am responsible for these fees if I miss or cancel an appointment without proper notice.
Medicaid (Oregon Health Plan)
• Medicaid covers most medically necessary behavioral health services.
• I will not be billed for Medicaid-covered services.
Self-Pay / Out-of-Pocket
• If I do not use or have insurance coverage, I agree to pay the applicable self-pay rates. I acknowledge that CFD’s Billing Department has discussed these rates with me.
1. Late Cancellation & No-Show Policy
• I agree to provide at least 24 hours’ notice if I cannot attend a scheduled appointment.
• If I miss an appointment or cancel with less than 24 hours’ notice, I may be charged a $40.00 fee.
• Insurance will not cover this fee, and I am personally responsible for payment.
• If I am covered by Medicaid (OHP), CFD will not charge this fee for missed or late-canceled appointments; however, my therapist will discuss attendance with me, and services may be suspended after multiple occurrences.
2. Payment Terms
• Unless otherwise specified by my insurance company during CFD's initial benefit check, I will be responsible for paying $25 at the time of service until insurance processing is complete and my responsibility is determined.
• Copayments are due at the time of service.
• Any cost quoted to me is an estimate, and charges will depend on claims processing or services rendered.
• Balances must be paid by the 25th of each month.
• Failure to keep my balance current may result in suspension from the program. If I am suspended, my balance must be paid in full ($0 balance) before I can be reinstated. Reinstatement will occur after my balance is paid in full.
3. Additional Information
• My information may be reviewed by my health plan, including the Oregon Health Authority or the local coordinated care organization, for funding authorization of services, quality improvement, utilization management and site review purposes.
• CFD will send me a monthly statement with the balance due.
• Charges for minors not covered by insurance will be billed to the legal guardian initiating services.
• CFD accepts payment by cash, check, VISA, or Mastercard.
4. Acknowledgment
By signing below, I acknowledge that I have read and understand this form, have had the opportunity to have my questions addressed, and agree to the above responsibilities.
If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.
Full legal name of Personal Representative:
Relationship to client:
Definition of Personal Representative:
For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.
For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.
