Recovery Fee Agreement
Name: Date of Birth: Effective Date:
CFD will submit claims to appropriate payers for services provided. By signing this form, the individual/guardian authorizes such billing and payment directly to CFD. The individual/guardian further authorizes CFD to provide necessary information to the payer to complete this billing.
I agree to and understand the following statements:
Payment for costs not covered by insurance, including co-pays and deductible, are due at the time of service.
I understand that my fee contract with CFD is as follows:
Oregon Health Plan Commercial Insurance UA testing not covered by Commercial Insurance. See below rates – Per service rates for Urinalysis Testing only: Standard UA $20, Targeted UA $35, Instant UA $10 Lane County Youth Services Intoxicated Driver Program Fund (IDPF) Per service rates (non-administrative rates): Assessment $150.00, Individual $80 ($20.00 per 15 minutes), Family $80.00, Group $40, Urinalysis Test (UA) $20.00 State Slot DUII rate of $325 per month (due at time of assessment and monthly thereafter) Other:
Individual qualifies for funding assistance based on information provided by individual/guardian to Billing Department, as summarized in Recovery Fee Agreement Worksheet: YesNo
DUII Diversion or Convicted clients only – I received a copy of the Financial Suspension Policy.
If applicable, 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.
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: Recovery Fee Agreement
Agree & Sign