City: State: Zip:
Home Phone: Cell Phone:
Date of Birth:
Estimated date of admission:
Client Name: Date of Birth:
Responsible Party Name:
Address, City, State, Zipcode:
Home Phone: Work: Cell:
By signing this agreement I acknowledge and confirm that I am personally liable for the cost of my stay and services at The Sanctuary at Sedona paying The Sanctuary at Sedona directly amount in cash (US currency) via one of the approved payment options.
The Sanctuary will 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.
I understand any payment returned by my banking institution for “Insufficient Funds”, “Stop Payment”, “Account Closed” or any other reason will immediately cause the account to become delinquent and thereafter placed in a collection status which may include referral to a collection agency. If this occurs, I promise to pay all attorney fees and other reasonable collection costs and charges necessary for the collection of any amount not paid when due. I understand that, if my account is referred to a collection agency, the collection fee is ordinarily eighteen percent (18 %) of the total outstanding balance due, for which I will be responsible in addition to the principal debt due and payable.
I have carefully and completely read this agreement and fully understand the purpose, intent and effect of this agreement. I have voluntarily executed the agreement by action of my own free will.