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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:

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

Self-PayCommercial InsuranceOther:

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: 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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Your legal name

Your email address

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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 65.157.96.202

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