Financial Responsibility: Santa Fe & Rio Arriba - Southwest Family Guidance Center & Institute

Financial Responsibility: Santa Fe & Rio Arriba

FOR SANTA FE AND RIO ARRIBA COUNTIES ONLY. Intake forms are securely encrypted and HIPAA compliant.

Financial Responsibility: Santa Fe & Rio Arriba

ID #
CLIENT FIRST NAME*
CLIENT LAST NAME*
CLIENT DOB*
MM slash DD slash YYYY
CLIENT EMAIL*
By signing below, I agree to assume responsibility for payment of all costs, charges, and fees to Southwest Family Guidance Center (SWFGC) for services performed that are not otherwise paid by insurance or other third-party payor programs in which I am enrolled. I understand that I may become responsible for paying any or all of the following:
- CO-PAYS
- DEDUCTIBLE AMOUNT
- CO-INSURANCE
- FEES FOR THERAPY SESSIONS I RECEIVE AT OR THROUGH SWFGC
- FEES FOR OTHER SUPPORT SERVICES AT OR THROUGH SWFGC
I understand that failure to maintain insurance coverage, provide current policy information to SWFGC, communicate insurance policy changes to SWFGC, or provide SWFGC with the information necessary to bill any applicable insurance or third-party payor will result in me being deemed financially responsible, and all fees for services provided by SWFGC will be due in full at the time of service.
GUARDIAN NAME*
RELATION TO CLIENT*
DATE
MM slash DD slash YYYY