Consent for Treatment: I consent to evaluation, treatment and care by ARC (ARC) staff and therapists.
Obligation for Payment: I hereby agree to pay usual and customary charges for all services provided by ARC, except those covered by insurance (which includes all commercial and government 3rd party payers. Such as HMO and Medicare) ARC will assist in insurance coverage matters, but I understand that it is my responsibility to comply with all requirements for insurance coverage. I agree to pay all charges that are not paid by insurance. In the event I fail to fulfill any of the obligations on this section, I agree to pay any and all collection costs incurred by ARC in the enforcement of this section.
Release of Information for Payment Purpose: I hereby authorize and consent to ARC release of medical information to obtain payments as described in ARC privacy notice.
Assignments of Benefits: I hereby irrevocably assign payments to ARC for all medical benefits applicable and otherwise payable to me. Where Medicare and Medicaid benefits are applicable, I certify that the information given by me in applying for payment, under title XVII or XIX of the social security act is correct and request of said payment of authorized benefits are made on my behalf. I understand that I am financially responsible to ARC for charges the carrier declines to pay. It is furthered agreed that any credit balance resulting from payment by my insurance or other sources may be applied to any other accounts owed to ARC by the insured or immediate family.
Cancellation, Rescheduling, No Show and Late Policy: In order to provide each patient with the highest quality service we ask that you call 24 hours in advance if you are unable to keep scheduled appointments. In the event the patient demonstrates disregard for this policy, a charge of $25 for each missed appointment will be assessed. We also reserve the right to refuse treatment if you are late to scheduled appointments in order ensure appropriate time and personal attention to each patient.
PDF format of the form may be downloaded here.
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