Recovery Fee Agreement


Center for Family Development

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

Recovery Program 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:

  • The individual/guardian will inform CFD of any changes in coverage as soon as possible. If the individual/guardian is covered by a payer for which coverage ends for any reason, individual/guardian 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 the responsibility of the individual/guardian. The statement will specify an amount due, if applicable. Fees are due on the 25th of each month.
  • Failure to keep the account current may result in suspension from the program. If suspended, the individual/guardian must ensure that the account balance is paid in full ($0 balance) for reinstatement into the program. In this event, reinstatement will occur on the first of the month following the month in which the balance was paid in full.
  • CFD accepts payment by cash, check, VISA or Mastercard for amounts owed by the individual/guardian.

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:

 

Individual qualifies for funding assistance based on information provided by individual/guardian to Billing Department, as summarized in Recovery Fee Agreement Worksheet:

DUII Diversion or Convicted clients only - I received a copy of the Financial Suspension Policy.

Commercial Insurance:

  • The individual/guardian has the responsibility to contact the payer(s) to verify coverage and benefits.
  • If treatment requires or the individual/guardian chooses to exceed the number of visits authorized by the payer, the individual/guardian will be responsible for payment of services exceeding authorized amount. Additionally, there may be other costs incurred related to treatment not covered by commercial insurance that cannot yet be estimated, such as consultation and case management; these costs will become the responsibility of the individual/guardian.
  • Unless otherwise specified by payer(s) during the initial benefit check conducted by CFD, the individual/guardian will be responsible for paying an amount of $25 at the time of service until CFD receives further information from the payer(s).
  • If CFD is out of network with the payer and/or the payer does not cover the service provided, the individual/guardian will be responsible to pay for any charges. If the payer compensates CFD for any portion of these costs, CFD will provide reimbursement for that amount.
  • If the individual/guardian is covered by a secondary payer, all necessary information of the secondary carrier must be provided to CFD to enable CFD to submit claims, as a courtesy to the individual/guardian.
  • I understand that if my insurance does not cover urinalysis, I will be invoiced at the following rates:
    Per Service Rates for Urinalysis if not covered by insurance: Standard UA $20; Targeted UA $35; Instant UA $10

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:

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: Recovery Fee Agreement
lock iconUnique Document ID: 12ec92f1828b12bb60ee8ef6597b55250a362580
Timestamp Audit
April 15, 2020 2:39 pm PDTRecovery 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 9:30 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
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 10:32 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