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LifeBack
4 Princess Rd
Suite 206
Phone 609-482-3701
Fax 609-482-3702
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Gender:  *  
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Thank you for choosing us as your health care provider.  We value and care for each patient. We are committed to providing you with the highest quality care. We understand each person may have unique financial circumstances, and we offer many financial accommodations. Kindly read the following statement outlining our financial policy.  Should you have any questions, our benefits coordinator will be glad to review them with you.

• We accept cash, credit cards, and personal checks for payment.
• Payment is due at the time services are provided unless other arrangements are made.
• Our office is out of network with most insurance plans however, we will bill your insurance carrier on your behalf.
• If you receive reimbursement for services rendered by Lifeback it is your responsibility to forward those payments to our office within ten days from the date of issue. Upon your request, the office will provide you with a pre¬-addressed stamped envelope. We appreciate your anticipated cooperation in this matter.
• Please notify Lifeback immediately if there are any changes to your health insurance coverage.
• If your insurance is terminated, coverage has lapsed, or your insurance company does not reimburse us for services rendered you will be financially responsible for those services.
• Payment plans are available for all insurance or coinsurance liabilities, fees, reports, and related expenses. Please ask our benefits manager for assistance.

Missed Appointments
Time has been reserved for your treatment when your appointment is confirmed. A late
cancellation or no-show fee of up to $50 is charged for each appointment canceled with less than 48 hours advance notice.

Collection Costs
If your account is referred for collection (after 120 days of non-payment) you will be responsible
for the balance, plus any collection costs or fees in the amount of 35% of the outstanding full balance.  Also, you will be responsible for all certified mail costs, court costs, and attorney's fees.

Insurance Authorizations
My signature below indicates I authorize my insurance benefits to be paid directly to Lifeback.  Additionally, I authorize Lifeback or my insurance carrier to release any information required to process my claims.  

My signature below also indicates I have read and understood this policy and agree to the terms and conditions.
Signature
Signer Type:  
  Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
  Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
   
Name:
 
Sign with Touch
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