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MH Fee Agreement

1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Mental Health Fee Agreement

Name: Date of Birth:

CFD will submit claims to the appropriate payers for services provided. I agree to and understand the following statements:

I will inform CFD of any changes in my coverage as soon as possible. If I am covered by a payer for which coverage ends for any reason, I may be responsible for the full cost of treatment.
CFD will provide a monthly statement listing services, payments and adjustments for the previous month that are my responsibility. The statement will specify an amount due, if applicable. Fees are due on the 25th of each month.
Charges for minors not covered by the payer will be billed to the legal guardian initiating services.
CFD accepts payment by cash, check, VISA, or Mastercard owed by individual/guardian.
Payment for costs not covered by insurance, including deductible and copays, are due at the time of service.

I understand that my payer and/or payer arrangement with CFD is as follows:

Medicare and/or Commercial Insurance Self-Pay

Bill client responsibility to:

Oregon Health Plan Secondary Insurance Client

Self-Pay:

Assessment: $150.00
Individual/Family: $100.00 ($25.00 per 15 minutes)
Group: $40.00
Case Management: $50.00 ($12.50 per 15 minutes)

Medicare and/or Commercial Insurance (if applicable)

I have the responsibility to contact the payer(s) to verify coverage and benefits.
I am responsible for any cost that is not covered by the payer(s). This does not include any portion that is the contracted discount with the payer(s).
If treatment requires or if I choose to exceed the number of visits the payer(s) has authorized, I will be responsible for payment of services exceeding authorized amount. Additionally, there may be additional costs incurred related to treatment not covered by Medicare/Commercial Insurance that cannot yet be estimated, such as consultation and case management services; these costs will become my responsibility.
Unless otherwise specified by the payer(s) during CFD's initial benefit check, I understand that I will be responsible for paying an amount of $25 at the time of service until CFD receives further information from my payer(s).
If CFD is out of network with the payer and/or if the payer does not cover the service provided, I will be responsible to pay for any charges. If the payer compensates CFD for any portion of these costs, CFD will then reimburse me the amount paid by the payer.
If I am covered by a secondary payer, I must provide all necessary information of the secondary payer to enable CFD to submit claims, as a courtesy to me.

If applicable, I authorize billing to my payer(s) and payment of medical benefits directly to CFD. I authorize CFD to provide information to my payer(s) that is necessary to complete this billing process.

By signing below, I acknowledge that I have read and agree to the above fees and responsibilities.

This document is being signed by: ClientPersonal Representative, see below

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.

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Timestamp

Audit

April 15, 2020 3:22 pm PDT

MH Fee Agreement Uploaded by Do Not Reply - donotreply@c-f-d.org IP 192.111.94.3

April 29, 2020 8:41 am PDT

Records Department - records@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129

April 29, 2020 9:40 am PDT

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129

May 5, 2020 9:31 am PDT

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 173.8.200.225

June 24, 2020 10:35 am PDT

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202

March 18, 2021 1:49 pm PDT

Document owner jdooley@c-f-d.org has handed over this document to donotreply@c-f-d.org 2021-03-18 13:49:19 - 65.157.96.202

March 18, 2021 1:49 pm PDT

CFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202

May 3, 2021 10:38 am PDT

CFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202

January 29, 2024 3:17 pm PDT

CFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 192.111.94.3