Camp & Community Programs - 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 for the 6-week group are: Warren MT Summer Groups 5 years and older
Camp Dates
Flat Fee
Total
9/3; 9/10; 9/17; 9/24; 10/1; 10/8
$150
$150
Total:
$150
I also understand that payment will be due at the time of service. Once we have received a signed self-pay form for your child, our billing department will follow up via email to confirm and provide instructions to make a one-time payment. If you have questions regarding payment please reach out to our billing department at 888-214-4826
Patient Name: ______________________________________________________________________ Patient DOB: ______________________________________________________________________ Guardian Name: ____________________________________________________________________ Signature: _______________________________________ Date: ________________________