Camp and Group Services: Self-Pay Agreement Form As the parent/guardian of the patient noted below, I authorize Cortica to provide and invoice the following programs. I understand this is a self-pay service not covered by my insurance. I understand the volume-discounted rates are: Type of Camp/Group Service
Camp/Group Dates
Flat Fee
Total
Total:
I also understand that payment will be due at the time of service. Payments can be made with the front office administrator or by contacting our billing department at billing@corticacare.com.
Patient Name: ______________________________________________________________________ Patient DOB: ______________________________________________________________________ Guardian Name: ____________________________________________________________________ Signature: _______________________________________ Date: ________________________