3.Financial Agreement and Assignment of Benefits: The undersigned agrees, whether he/she signs as agent or as a client, that in consideration of participation of the client in an outpatient program within the scope of MDYFSC, and of the services rendered to the client, he/she hereby individually obligates himself/herself to pay the account of MDYFSC in accordance with the regular rates and terms of the facility. If is agreed that MDYFSC will verify and file of any benefits available from insurance carriers. The undersigned authorizes payment directly to MDYFCS of the outpatient benefits otherwise payable to him/her for the treatment of the client. It is understood that MDYFSC will reimburse the client, his/her agent, or third party (as appropriate) when overpayment for services occurs. 4. I authorize the release of any medical information necessary to process my insurance claim. 5. Client Information Sheet: The client and/or agent has received a Client Information Sheet which provides information related to the Credentialing of mental health providers, fees for services, appointment scheduling procedures, actions taken in urgent or after hours situations, Client Rights, and other pertinent information.
The undersigned accepts the term hereof, certifies that he/she has read the foregoing, has received a copy thereof and is the client authorized to sign as the client's agent.