MH Fee Agreement


Center for Family Development

1258 High Street, Eugene, OR 97401 541-342-8437 / Fax 541-242-2999

Mental Health Fee Agreement

Name:     Date of Birth:

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

 

I understand and agree to the following statements:

  • I will receive a monthly statement listing services, payments, and adjustments. The statement will specify an amount due from me, and I understand payment is due upon receipt.
  • 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.
  • It is possible that there may be additional costs incurred, related to counseling that cannot yet be determined.

Self-Pay (if applicable)

Amount agreed per session:

Commercial Insurance (if applicable)

*Payment for costs not covered by insurance are due at the time of service. *

  • CFD will submit claims for services provided to the appropriate payers. I authorize billing to my insurance company and payment of medical benefits directly to CFD. I authorize CFD to provide information to my insurance company that is necessary to complete this billing process.
  • Payment for costs not covered by insurance are due at the time of service.
  • I have the responsibility to contact my insurance carrier(s) to verify coverage and benefits.
  • I will inform CFD of any changes in my coverage as soon as possible.
  • I am responsible for any cost that is not covered by my insurance carrier(s). This does not include any portion that is the contracted discount with the carrier(s).
  • If I choose to exceed the number of visits my insurance carrier(s) has authorized, I will be responsible for payment of services exceeding authorized amount.
  • Unless otherwise specified by my insurance carrier(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 insurance carrier(s).
  • I understand that commercial insurance does not pay for consultation or case management services, and I will be responsible for these costs if these services are provided.
  • If CFD is out of network with my insurance carrier and/or if the insurance plan does not cover the service provided, I will be responsible to pay for any charges at the time of service. CFD will then reimburse me the amount paid by the insurance carrier.
  • If I believe I may be covered by a secondary carrier and provide all necessary information of the secondary carrier, CFD will submit claims as a courtesy to the client.

Other (if applicable)

Describe:

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:

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.


Leave this empty:

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CFD Client Forms https://esign.c-f-d.org
Signature Certificate
Document name: MH Fee Agreement
lock iconUnique Document ID: 8e592fcd398eb629dbabaab2b8551b06d6991e60
Timestamp Audit
April 15, 2020 3:22 pm PDTMH Fee Agreement Uploaded by Jason Dooley - jdooley@c-f-d.org IP 65.157.96.202
April 29, 2020 8:41 am PDTRecords 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 PDTCFD 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 PDTCFD 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 PDTCFD 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