Copayment / Private Pay Agreement

Copayment / Private Pay Agreement

Complete this form to record agreement details, payment information, and acknowledgment electronically for A Core Connection Services & Consulting.
Client and Coverage Information
Client Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
FINANCIAL RESPONSIBILITY: I understand that I will be responsible for all charges that my funding source does not cover, including services not covered in my plan, services more than the allowable amount in the plan, services provided after coverage lapsed, fees described in the Cancellation/No Show Policy, or any other reason for insurance non-payment.

NOTE: During the assessment and reassessment periods, there may be additional charges for indirect services related to assessment (e.g., data analysis, report writing) outside of sessions.

My current insurance coverage includes the following (actual cost may change after insurance processes claim):
Insurance Coverage
Insurance Details (Session Fee disclosed to you at time of verification)
Payment Method and Service Fee Details
Payment method

Other
Payment method - Other
Credit Card and Billing Details
Name as It Appears on Card

First NameLast Name
Payment Card Type
Card Number
Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Security Code
Billing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Agreement Acknowledgment and Signature
Agreement text
Acknowledgment

I understand that failure to pay a charge for one session will require that both charges be paid at the next session. Failure to pay charges for two sessions will result in suspension of services until payment is made. This agreement may be amended or terminated at any point. Termination of this agreement does not relieve the obligation to pay for services that have already been rendered. By signing below I am authorizing my card listed above to be charged for sessions provided. I have read, understand, and agree to the Copayment / Private Pay Agreement.
Cardholder Signature
Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Copayment / Private Pay Agreement

Client and Coverage Information

Payment Method and Service Fee Details

Credit Card and Billing Details

Agreement Acknowledgment and Signature