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   ROI-Orchard Medical

 

Financial Agreement for Services

(This is a binding contract and required before we can provide treatment services. Please read carefully and sign at the bottom)


Recovery Help provides contract services to Orchard Medical for your care.  This means that Recovery Help will not send you any billings for these services. Instead, Recovery Help bills Orchard Medical for the services provided to you.

If you have any questions about your financial obligation such as co-pays, deductibles, etc. you should direct them to your primary provider, Orchard Medical.

Additional Services

If you desire additional services from Recovery Help that are not authorized by Orchard Medical, Recovery Help will provide a written quotation for those services and you must approve the services in writing prior to receiving the services.

Electronic Signature

You further understand that when you interact online with Recovery Help systems and websites that your typed name becomes your electronic signature in place of your written signatures. You also understand that faxed or scanned copies of documents with my typed signature are to be considered original signatures.
Acknowledgement
By signing below, I acknowledge that I have read, understand and agree to the terms and conditions stated above.

Signature (Type Your Name)..