In today’s economic times, we understand the hardships you may be going through, and we want to work with you to resolve your balance. I understand that I am agreeing to the following payment plan between myself and Rainier Behavioral Health. I further understand that I must sign and submit this electronic agreement for it to be valid.
I further understand that if claims are still pending with insurance at this time that I may owe an amount in addition to the amount listed above and furthermore, agree to pay that amount based on this plan as well.
On back of card
Any questions or concerns that I may have had concerning this agreement were answered or discussed with one of the staff members at Rainier Behavioral Health. If this agreement needs to be altered at any time, I will contact the Practice Manager at 253-475-6021 ext.102 to discuss further options.
PLEASE NOTE: All payments must be paid monthly. All unpaid balances 120 days or older will be considered for third party collections
I acknowledge I have read the financial policy above and that I am responsible for all charges regardless of any insurance coverage I have. I understand that delinquent accounts may be assigned to a credit reporting collection agency and agree to pay for all legal costs and expenses including reasonable attorney fees. By signing this Acknowledgement, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding