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2024 CC

Insurance and Ancillary Payment Authorization Form

Patient Name:

Guarantor Relationship:

Admission Date:

Cost:

Cost Due at Time of Admission for Insurance: ______

Coinsurance or Out-of-Pocket Maximum due: ______

I understand and acknowledge my insurance will authorize residential and partial hospitalization benefits for care, pending medical necessity, and various charges, such as food, board, ect are not a billable service at PHP level of care. Therefore, I agree to pay additional costs to cover these charges, when a step down is determined by my insurance and have the option to transfer into that level of care with Peaks Recovery Centers. The cost for food and housing is an additional $1,000.00 for the 3 week program: ______
I understand TMS therapies may not be covered by my insurance, therefore, if that is a service that is approved by the Peaks Team and I wish for myself or loved one to do, I am aware that may be an additional out of pocket cost of $1,500.00 :______

Total Due at Time of Admission: ______

Authorization to charge Credit Card for fees: __________ (Yes/No)

Credit Card Information

Card Holder Name: _________________________________________________________

Type of Card:_________ Credit Card Number: ___________________________________

Expiration Date:________ CCV Code: _________

Billing Address: ________________________________________________________

City: ___________________ State:_______________ Zip Code: _______________

Phone Number associated with credit card: ___________________________________

Email associated w/ credit card: ________________________________________

Being the cardholder or Corporate Officer, by signing below I agree to pay the above stated costs for treatment services rendered to the above named patient and specifically authorize Peaks Recovery Centers, LLC to charge my credit card. I further agree that in the event my credit card becomes invalid, that, I will provide Peaks Recovery Centers with a new valid credit card upon request, to be charged for the payment of any outstanding balances owed to Peaks Recovery Centers.

I further agree and understand that upon completion of Intake Services provided to the above named patient, that there is a non-refundable fee of $5,000.00that will be retained by Peaks Recovery Centers, LLC for services rendered. I also understand that if the above named patient does not admit into Peaks Recovery Centers’ recovery program, for any reason, that my card will not be charged.

Printed Name:____________________________ Date:_____________Guarantor Signature:_______________________________________________

Client Admission Attestation

Peaks Recovery Centers (PRC) holds client and staff safety in the highest regard. In order to

help ensure the safety of the clients and staff, our Admissions and Clinical Teams collect data

about the potential client during the admissions process. It is imperative this information is

accurate so PRC may establish appropriateness for the potential client to receive treatment with

our organization.

I, ________________________________, have applied for admission to PRC treatment

program. I attest that I have provided accurate and true information to the Admissions and

Clinical Teams, including but not limited to:

● Legal History

● History of Violence

● Medical Care Needs and/or History

● Any Behavioral and Cognitive Concerns

● Any information that is believed to be pertinent to my treatment stay with Peaks

Recovery Centers

I, ________________________________, understand that any falsification, omission, or

concealment of material fact may subject me to administrative, civil, or criminal liability,

including immediate discharge from Peaks Recovery Centers and the refund policy will be

followed.

By signing below, I attest that the information bullet pointed above and provided to the

Admissions and Clinical Teams during the admissions process is true, accurate and complete to

the best of my knowledge.

Potential Client Signature: ________________________________ Date: _________________

Admissions Specialist Signature: ___________________________ Date: ________________

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June 11, 2024 12:10 pm MDT

2024 CC Uploaded by Sun Point - admin@sunpointvenue.com IP 2601:281:d980:9740:9da9:5a46:799c:4879