• FINANCIAL RESPONSIBILITY ACKNOWLEDGMENT

  • At Allied Comfort & Care, we are committed to providing high-quality, compassionate mental health care. We are also committed to transparency regarding our fees, insurance billing practices, and your financial responsibility.
  • Please read and sign this Financial Responsibility Acknowledgment form.

  • PATIENT INFORMATION

  • Date of Birth:*
     - -
  • Format: (000) 000-0000.

  • FINANCIAL RESPONSIBILITIES

  • I understand and agree to the following:
    • Insurance: I understand that I am responsible for providing accurate and complete insurance information. I authorize Allied Comfort & Care to bill my insurance company for services provided.
    • Insurance Benefits: I understand that verification of benefits is an estimate and not a guarantee of payment. I am responsible for knowing my insurance benefits, including copays, coinsurance, deductibles, and limits.
    • Patient Responsibility: I understand that I am responsible for all charges not covered by my insurance, including but not limited to copayments, coinsurance, deductibles, non-covered services, and services deemed not medically necessary.
    • Payment: I agree to pay any amounts due at the time of service or as billed by Allied Comfort & Care. If I am unable to pay at the time of service, I agree to make payment arrangements.
    • Missed Appointments: I understand that I may be charged a fee for missed or late-cancelled appointments, as outlined in the practice's Missed Appointment Policy.
    • Collection Responsibility: I understand that if my account is sent to collections, I will be responsible for all collection fees, costs, and any legal fees incurred.
    • Updates: I agree to notify Allied Comfort & Care of any changes in my insurance coverage, contact information, or financial responsibility.

  • ACKNOWLEDGMENT

  • By signing below, I acknowledge that I have read, understand, and agree to the above Financial Responsibility Policy. I understand that I am ultimately responsible for payment of all services rendered.
  • Date:*
     - -
  • Thank you for choosing Allied Comfort & Care. We appreciate your trust and partnership in your care.
  • 236 W ALLEGHENY AVE PHILADELPHIA, PA 19133-3629 | 215-989-1771 | admin@alliedcomfortncare.com
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