Rainier Behavioral Health Payment Plan

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.

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