Financial Agreement Form

Please fill out Online or Download and bring in
Payment is due when services are rendered. If you have insurance to cover your services, please verify your
coverage at the time of service.

1. I agree that I am responsible for this debt regardless of my insurance and that I will pay any unpaid
balance, in full, within 60 days of the date of service. A $20.00 rebilling charge will be added each month
after the account is more than 60 days past due.

2. In the event that my account becomes delinquent, I agree to pay a collection agency fee of 100% of my
unpaid balance in addition to my balance.

3. In the event that legal action is necessary to collect this bill, I agree to also pay reasonable attorney’s fees
and costs of court and agree to submit to the jurisdiction of the Court.

4. If any portions of this bill or the provider’s services are disputed, I agree to submit myself to mediation or
arbitration and will pay the costs in doing so.

5. I understand that a charge of $80 will be made for missed appointments which are not canceled 24 hours
in advance of the appointment time. I understand that insurance companies do not cover this charge.

6. In compliance with our insurance contracts, copays and deductibles must be paid by cash, check or credit card the day of your appointment. A credit card number will be kept on file to pay for insurance deductibles, co-pays, late cancellations, no shows, and any balance due on your account. Your signature on this form authorizes use of that credit card for those charges. You will be notified when a charge has been made.

The undersigned person(s) hereby agrees to all stipulations above and to pay all professional services
rendered by Corner Canyon Counseling and Psychological Services in accordance with this agreement.

By typing your name you have created an electronic signature as legally binding as your handwritten signature.

Phone: 801.438.6059 | Fax: 801.501.0249

Draper Office

248 East 13800 South, #4
Draper, UT 84020

Bluffdale Office

14241 South Redwood Road Suite 100
Bluffdale, UT 84065