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Recovery Program Fee Agreement Confirmation

Full Name: Date of birth:

I have reviewed the Recovery Program Fee Agreement completed by my therapist.

I confirm that it is accurate.

The following information is not accurate (select all that apply):

Payer Source Copay Responsibility

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Your legal name

Your email address

Please Confirm full name and signature.

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Timestamp

Audit

December 4, 2020 11:43 am PDT

Recovery Program Fee Agreement Confirmation Uploaded by Do Not Reply - donotreply@c-f-d.org IP 65.157.96.202

March 18, 2021 2:55 pm PDT

Document owner jdooley@c-f-d.org has handed over this document to donotreply@c-f-d.org 2021-03-18 14:55:23 - 65.157.96.202

March 18, 2021 2:55 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 8:49 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