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This Financial Responsibility Agreement (“Agreement”) is entered this day of , 20(“Effective Date”), between The Sanctuary at Sedona Inc., located at 2675 W. State Route 89A, #1115, Sedona, Arizona 86336 (“The Sanctuary”) and {name} whose address is (“Resident” or “you”). The Sanctuary and Resident agree that the following terms govern the provision of the Holistic Addiction Recovery Program (“Program”) by The Sanctuary to Resident and the compensation of Resident for that Program.

A.Program Fees:

1. Single Room: The Program Fee for Resident for a private room is Forty-One Thousand, Four-Hundred Dollars ($41,400) based on a thirty (30) day stay. If your stay is shorter than 30 days, you will be charged on a pro-rata basis and will incur Use and Severance Tax (See Appendix A, The Sanctuary at Sedona Inc. Statement of Intent to Lodge in Excess of Thirty (30) Days, attached).

2. Double Room: The Program Fee for Resident for a double room is Thirty-Nine Thousand, Four-Hundred Dollars ($39,400) based on a thirty (30) day stay. If your stay is shorter than 30 days, you will be charged on a pro-rata basis and will incur Use and Severance Tax (See Appendix A, The Sanctuary at Sedona Inc. Statement of Intent to Lodge in Excess of Thirty (30) Days, attached).

Room and board and all Program sessions are included in the Program Fee. You are responsible for all other costs and expenses.

B. Payment: Payment of the full Program Fee must be made prior to, but no later than, your arrival at The Sanctuary. You may pay by wire transfer, EFT, personal check, cashier’s check, PayPal, or by credit card. Post-dated checks will not be accepted.

C. Insurance: The Sanctuary may be able to directly bill your insurance to cover all or part of your Program Fee. If we can bill your insurance provider and receive an acknowledgment from that provider of coverage, you will only be responsible for that amount of the Program Fee not covered by your insurance including all deductibles and co-pays. Arrangements regarding the amount you need to pay on admission to cover the portion of the Program Fees not covered by your insurance were made with you prior to admission.

Insurance coverage does not replace your financial responsibility. Payments received from insurance providers (if any) will be applied to those services corresponding to the insurance payments received.

1. Healthcare Savings/ Flexible Spending Accounts: If you have a healthcare savings account (HSA) or flexible spending account (FSA) plan, we will provide you with documentation for your expenditures that you can submit for reimbursement. The amount reimbursed is determined by your account plan. You will be responsible for the full Program Fee unless satisfactory arrangements are made prior to your admission to have payments made by your HSA/FSA provider directly to The Sanctuary.

2. Cooperation with Billing Company: Health insurance companies and medical benefit programs vary substantially in the way they cover mental and behavioral health treatment. To ensure payment by insurance companies, The Sanctuary has entered into a service agreement with Elevated Billing (“EB”), a company that specializes in substance abuse & mental health insurance billing services. You must work with and fully cooperate with EB in its efforts to collect insurance payments.

 

You understand and agree that although insurance, if available, will be billed consistent with The Sanctuary’s rates, insurance companies regularly develop and execute strategies designed to delay and avoid paying patient claims. Accordingly, your cooperation is absolutely necessary to successfully collect insurance payments and you agree to fully cooperate and do everything in your power to maximize insurance payments.

 

Even though The Sanctuary and EB will relentlessly advocate for payment by insurance providers, you understand and agree that you are responsible: (1) to obtain appropriate insurance payments; and (2) to pay the Program Fees stated above. You will assure that all payments owed to The Sanctuary are paid. You understand and have been advised that neither The Sanctuary nor EB can guarantee insurance will pay the Program Fee.

3. Assignment of Insurance and Right of Recovery: Resident irrevocably assigns and transfers to The Sanctuary all rights, title, and interest in the benefits payable for services rendered by The Sanctuary for all policies of insurance, as well as any and all claims for breach of fiduciary duty. This assignment shall NOT be construed to obligate The Sanctuary in any way to pursue any such right or recovery. This assignment and transfer shall not diminish or remove Resident’s standing to make claim or sue for benefits individually, should coverage be denied by any insurance carrier. Resident authorizes any insurance company to pay directly to The Sanctuary any and all benefits due under said policy by reason of services rendered. Resident agrees, upon The Sanctuary’s request, to execute any additional documents reflecting this assignment including an Assignment of Benefits Form.

4. Insurance Company Payments: The parties to this Agreement agree that all payments made by insurance companies are intended to pay for The Sanctuary’s medically necessary services. The Parties agree that if any insurance payment is sent directly to and received by Resident, Resident shall, within five business days, forward such payments without deduction to The Sanctuary, and if the Resident retains those payment he/she may have committed fraud.

D. Insurance Overpayment or Underpayment.

In the event your insurance company does not pay the full amount it committed to pay at the time of your admission, you will be charged the difference between what it committed to pay and what it actually paid. After payment has been received from your insurance company, if the amount received is less than the previous commitment, you will be billed for the difference. Payment of this invoice is due within 30 days of the date of the bill. Any amounts unpaid within 30 days of the date of the bill will incur interest at the rate of 18 percent per annum.

 

In the event your insurance company pays more than it committed to pay at the time of your admission, and the total amount received by The Sanctuary for the Program Fee is greater than $41,400.00, a refund of the difference received between the amount paid by you and your insurance company for the Program Fee will be refunded to you. Any amounts paid by you or your insurance company for the Non-Program Fees, additional Supplement Costs, taxes, Administrative Fee, or other services will not be considered when determining whether the amount received by The Sanctuary totals more than $41,400.00

E. Dishonored Payment Charges: Any dishonored payment (such as an insufficient funds check or disputed credit card charge) will be charged interest at the rate of 18 percent per year until fully paid. You will also be responsible for all bank or credit card processing fees The Sanctuary incurs as a result of the dishonored payment.

F.Commitment Fee: If you schedule your admission more than five days in advance of the date you intend to arrive, you must pay Commitment Fee of $5,000.00 to reserve your room. In the event, you change your mind prior to scheduled arrival date, a refund may be issued under the following circumstances.

1. If notice of the cancellation is received more than 14 days prior to your arrival date a $500.00 administrative fee will be charged and $4,500.00 will be refunded to you; or

2. If notice of the cancellation is received less than 14 days prior to your arrival date, your entire Commitment Fee will be forfeited and no refund will be issued.

To cancel your reservation, you must provide notice to The Sanctuary by email Order Valium Europe.

The Commitment Fee, once paid, is applied toward the balance of the Program Fee.

G. Transfer and Self-Discharge

1. The Sanctuary reserves the right, at any time, to refer or transfer any Resident to a different or higher level of care based on its evaluation of a Resident’s needs, or to discharge a Resident because they are unable to engage in or progress in treatment, also known as a Therapeutic Discharge. You understand the transfer or discharge is believed to be in your best interest and is not grounds for seeking a refund of any Program Fee incurred prior to the date of the transfer or discharge or the Administrative Fee specified below.

2. If a Resident receives a Therapeutic Discharge, that is, is transferred to a different or higher level of care or is discharged because they are unable to engage in or progress in treatment,the Resident will be assessed an Administrative Fee of $5,000.00plus a daily fee of $1,380.00 (“Daily Fee”) for each day the Resident was in the Program. If the Program Fee paid by the Resident exceeds the total of the Daily Fees and the administrative fee plus all applicable taxes, a refund will be issued to the Resident. All applicable sales and use taxes will be deducted from any refunds issued. Refunds will be processed within 30 days of the Resident leaving the Program.

3. If a Resident Self-Discharges prior to Day 18 of the 30 day program the Resident will be assessed an Administrative Fee of $5,000.00 plus a daily fee of $1,380.00 (“Daily Fee”) for each day the Resident was in the Program. If the Program Fee paid by the Resident exceeds the total of the Daily Fees and the administrative fee plus all applicable taxes, a refund will be issued to the Resident. All applicable sales and use taxes will be deducted from any refunds issued. Refunds will be processed within 30 days of the Resident leaving the Program

4. If a Resident Self-Discharges on Day 18 or after of the 30 day program the Resident there will be no refund issued to the Resident.

H. Non-Program Costs: Unless otherwise provided in this Agreement, the Program Fee does not include the cost of medications, Medical Care Costs, Psychiatric treatment or counseling, testing/ laboratory work, or the costs of outside providers. You agree to pay these costs. You also agree that upon admission, or upon any subsequent request, you will provide your original insurance card or an enlarged copy of the front and back of the card to us. In the event your insurance coverage changes during your stay, you agree to notify The Sanctuary immediately and provide a new original card or an enlarged copy of the front and back of your new card. The Sanctuary will relay this information to any outside providers to assist you in arranging for payment of the following costs.

Regardless of the assistance we may provide in relaying insurance information, you agree that you will make payment arrangements with all providers sufficient to cover the cost of the following:

1. Medication or Prescriptions including the payment of all co-pays, deductible, or uncovered medications.

2. Medical Care including any charges for ambulance transport to a hospital, non-emergency medical transport, emergency room, hospital, urgent care, doctor visits, or other medical treatment and all co-pays, deductibles, or non-covered treatment.

3. Psychiatric Care including all co-pays, deductibles, or non-covered treatment. However, the Program Fee does cover the costs associated with an initial evaluation by The Sanctuary’s Psychiatrist, but not the cost of any recommended lab tests, studies, or subsequent treatment.

4. Laboratory/Testing costs including all co-pays, deductibles, or non-covered expenses. The Sanctuary’s Psychiatrist may recommend lab work or testing during the initial evaluation, the cost of any recommended lab work or testing is not included in the Program Fee.

None of the foregoing providers will be permitted to bill The Sanctuary for services provided to you. You are solely responsible for filing any insurance claims for reimbursement for amounts paid for the foregoing services.

I. Supplement Costs: You will be provided The Sanctuary “Power Up Your Brain” initial Supplement Protocol and the cost of this initial Supplement Protocol is included in the Program Fee. Any additional supplements are not included in the Program Fee and you are responsible for payment of any additional supplements/vitamins.

J. Property Damage: If you cause or contribute to any damage to The Sanctuary’s property, you will be charged for the cost of repair. If the property cannot be repaired, you will be charged the cost to replace the damaged property.

K. No Guaranty: You understand The Sanctuary does not make any guarantees whatsoever, expressed or implied, regarding the effects, outcomes, or success of your participation in the Program or The Sanctuary’s services. You understand that you are responsible for the fees set forth in this Agreement regardless of the effect, outcome, or success of your participation in the Program or from The Sanctuary’s services.

L. Termination: Except as otherwise provided herein, this Agreement shall remain in full force and effect until Resident leaves The Sanctuary; however, Resident’s obligation to pay any unpaid fees or costs is not extinguished by the termination of this Agreement. Further, paragraph I above, will not be affected by any termination of this Agreement.

M. Collection Costs: If amounts owed to The Sanctuary are not paid within 30 days of the date they are due; your account may be turned over to a collection agency. You agree to pay all costs associated with collection of your account, including collection agency fees, attorney’s fees, interest, court costs, and other costs or fees incurred.

N. Severability: Should any provision of this Agreement be declared invalid or unenforceable, the remaining portions of the Agreement shall not be affected and this Agreement shall be construed in all respects as if such invalid or unenforceable provision was omitted.

O. Choice of Law and Venue: It is the intention of the parties to this Agreement that the laws of the State of Arizona shall govern the validity of this Agreement, the construction of its terms, and the interpretation of the rights and duties of the parties, without giving effect to any choice or conflict of law provision or rule. Any action involving or relating to this Agreement shall be brought in the state court of Yavapai County, Arizona. The prevailing party in a legal action to enforce this Agreement is entitled to reasonable attorneys’ fees and court costs incurred.

P. Successors and Assigns: The Sanctuary and Resident each binds itself and its successors, executors, administrators, and assigns to the other parties of this Agreement and to the successors, executors, administrators, and assigns of such other party, in respect to all covenants of this Agreement.

Q. Headings: Section headings are not part of this Agreement and are not intended to be a full and accurate description of the contents hereof, they are merely illustrative.

R. Waiver: Waiver by one party of a breach of any provision of this Agreement by the other party shall not operate as or be construed as a continuing waiver.

S. Modification or Amendment: This Agreement may be modified or amended ONLY if the amendments are made in writing and signed by both parties.

T. Entire Agreement: This Agreement sets forth the entire agreement between the parties, and replaces and supersedes any and all other contracts, agreements, and understandings, written or oral, relating to the subject matter hereof.

I, {name} acknowledge by my signature below that I have completely read this Agreement, understand the contents thereof, have had the opportunity to have any of my questions about this Agreement answered, and am willing and capable of providing the resources necessary for successful completion of The Sanctuary’s Program, and that I am signing this Agreement freely and willingly.

Furthermore, I understand the payment and refund policy outlined in this Agreement.

(Printed Name)

(Address)

(City, State, Zip)

(Telephone)

(Email)

(Signature)

(Date)

GUARANTY

I, {name} have a personal interest in {Resident’s name} receiving addiction recovery services provided by The Sanctuary.

I have read the Financial Responsibility Agreement between The Sanctuary and {Resident’s name}I understand the contents thereof, have had the opportunity to have any of my questions about this Agreement answered, and am willing and capable of providing the resources necessary for {Resident’s name} successful completion of the Program.

I am willing and capable of guaranteeing the resources necessary for the Resident’s successful completion of The Sanctuary’s Program.

(Printed Name)

(Signature)

(Date)