BRIGHT FUTURE

PRACTICE FINANCIAL AGREEMENT
Member Name

First NameLast Name
Monthly Income:
Source Of Income:
Does member have MA?

YesNo
If yes, MA#
Type
Exp. Date

MonthDayYear
Date
If other insurance, name of company
Policy #
Will member be billed?

YesNo
If yes, amount of charge per day:
It has been explained to me Bright Future Community Health Care Services policy. I understand that if I do not have insurance coverage, I may be billed by BFCHCS for receiving any of the services provided by BFCHCS. I also understand that fees are collected monthly and that special circumstances can be discussed with the Program Director.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

PRACTICE FINANCIAL AGREEMENT