ADM06-0125, 11/16, 5/17, 06/20
Client Payment Responsibility Agreement
Waukesha County Department of Health and Human Services (Provider)
TAX ID: 39-6005756
TEL: 262-548-7212
Member (Client) Name: DOB:
Insurance Plan Name:
Subscriber ID: Group Number:
By signing below, I agree to pay Provider for those Services determined for the reason(s) specified below:
• Not medically necessary;
• Otherwise not a covered benefit or excluded under my coverage
I understand, pursuant to the Provider’s Agreement with ,
that a Provider may not charge me for a service or supply determined not to be Medically Necessary by
my insurance plan unless I have specifically agreed in writing, prior to delivery of such services or
supplies, to be personally responsible for and pay for such services and supplies. Prior to signing this
Client Payment Responsibility Agreement, I understand that my insurance plan determined that the
services and supplies listed below were not Medically Necessary/not a covered benefit and excluded
under my coverage, and thus not covered by my health plan or insurance. I understand that I may appeal
any determination that a service or supply is not Medically Necessary and also authorize the provider to
appeal such a determination on my behalf. I further understand nothing in this Agreement may be
construed to limit any other rights I have under state or federal law. I also understand that receipt of such
services or supplies without my signature below cannot be charged to me personally.
I understand that, for the specified services and supplies listed below received after the date of signature
below, I will be personally financially responsible for payment for such services and supplies directly to
the Provider and that they are not covered by my health plan or insurance, even though the cost for these
services and supplies may not be shown on my Explanation of Benefits (“EOB”) as my financial
responsibility. I also understand that an appeal of a non-Medical Necessity determination does not assure
that I will not be personally financially responsible for services or supplies related to the appeal.
Description of Services and/or Supplies
Client Responsibility
(Cost)
Signature of Patient or Power of Attorney or Guardian or Legal Representative*
* If signed by a person other than the client, complete the following:
Unable to sign due to disability
* If you check any of the above boxes, you must have proof of legal authority (i.e. Guardianship Papers, Power of Attorney documents) *
CPT 90791 Psychiatric diagnostic evaluation/interview without medical service
click to sign
signature
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click to sign
signature
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