Financial Responsibility Agreement

Client Name:

Date of birth:

I understand and agree that I will be financially responsible for any and all charges for services not paid by my insurance for my visits.
I understand and agree it is my responsibility and not the responsibility of Inner Light Counseling to know if my insurance will pay for my service.
I understand and agree it is my responsibility to know if my insurance has any deductible, co-payment, co-insurance, out-of-network amounts, usual and customary limit, or any other type of benefits limitation for the services I receive, and I agree to make full payment whenever required.
I understand and agree it is my responsibility to know if the provider I am seeing is a contracted in-network provider recognized by my insurance company or plan. If the provider is not recognized by the insurance company or plan, it may result in claims being denied or higher out-of-pocket expense to me. I understand this and agree to be financially responsible and make full payment.
I understand that Inner Light Counseling may charge a $100 fee for cancellations without a minimum 24 hour notice.
I understand that if I need a copy of my medical records, a printing fee may be charged.
I understand that any forms to be filled out by the providers may have a fee assessed.
I understand that I will be required to provide a valid form of payment which will be run electronically.
I understand that any account balance that is 90 days past due will be sent to collections and that it is my responsibility to ensure that my insurance and contact information is always current and updated.

Signature

Date