Financial Responsibility

I hereby authorize payment of medical/mental health benefits directly to Fusion Family Consulting and/ or the attending physician for services rendered. Authorization is hereby granted to release information contained in die patient’s medical record to die patient’s medical insurance company (or its employees or agents) as may be necessary to process and complete the patient’s medical insurance claim. I understand that this authorization may include release of information regarding communicable diseases, such as Acquired Immune Deficiency Syndrome (“AIDS”) and Human Immunodeficiency Virus (“HIV”). I understand that I am financially responsible for the total charges for services rendered which may include services not covered by the patient’s insurance companies. I agree that all amounts are due upon request and are payable to Fusion Family Consulting. I further understand that should my account become delinquent, I shall pay the reasonable attorney fees or collection expenses of Fusion Family Consulting, if any. The duration of this authorization is indefinite and continues until revoked in writing I understand that by not signing this release of information, I am responsible for payment of services in full before the services are rendered.

Signature of Patient, Parent, or Legal Guardian