PLEASE READ BEFORE SIGNING
GUARANTEE OF PAYMENT AND ASSIGNMENT OF INSURANCE BENEFITS
I take full responsibility for the cost of the services provided to me and/or my family and agree to pay for all services that are not reimbursed by my insurance carrier or other anticipated payor. I also authorize my insurance carrier/other payor to pay Dr. Alan Kleinkopf, clinical psychologist, for covered services and agree to the release of medical information necessary for billing purposes. It is further agreed that in the event any payments received by Dr. Kleinkopf from the insurance carrier which are at any time after their receipt withdrawn from Dr. Kleinkopf by the insurance carrier, I will be responsible for those payments then due and owing, and waive any defense for payment I may have. The balance is due within 30 days of notification. Otherwise, the undersigned promises to pay in addition, all costs of collection and reasonable attorney fees incurred therein. I understand that any portion of the account balance not paid within 30 days of notification will be subject to a finance charge of 1 1/2% per month (or 18% annually). I understand that I may be charged and agree to pay the full fee for appointments that are not cancelled at least 24 hours prior to the appointment.
