MH 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:
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. *
Other (if applicable)
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.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: MH Fee Agreement
Agree & Sign