BIRCHES HEALTH FINANCIAL RESPONSIBILITY AGREEMENT
Effective Date: 2/9/2026
This document explains your financial responsibilities for services.
Fees and Payment Responsibility
You agree to pay for services received, including any copays/coinsurance/deductibles or self-pay amounts, as applicable.
Insurance
We may bill your insurance plan if we are in-network/out-of-network as applicable. You are responsible for amounts not covered by your plan.
State-Funded or Government-Contracted Coverage
Birches Health may provide services under certain state-funded or government-contracted programs for individuals who meet applicable eligibility criteria.
Eligibility for such programs is determined by the applicable state agency or contracting entity and may require verification before services are covered. Coverage is not guaranteed, and services provided before eligibility is confirmed may be the patient’s financial responsibility.
If you are approved for state-funded coverage, Birches Health will apply the applicable contract terms to covered services for the period of approved eligibility.
If you believe you may qualify for state-funded or government-contracted coverage, you agree to notify Birches Health as soon as possible so eligibility can be reviewed prior to or during intake.
No Guarantee of Coverage
Insurance coverage decisions are made by your insurer. We cannot guarantee coverage or payment.
Missed Appointments / Late Cancellations
If you miss an appointment or cancel late (within 24 hours of the scheduled appointment time), you may be charged: $125 if permitted by applicable law and payer rules.
No Surprises Act Notice
For information about your rights under the federal No Surprises Act and how to obtain a Good Faith Estimate if you are uninsured or self-pay, please review our good faith estimate notice.
Financial Responsibility Acknowledgment (Electronic Attestation)
By selecting “I Agree,” continuing with scheduling, or receiving services from Birches Health, you acknowledge that you have read and understand this Financial Responsibility Agreement and agree to the terms described above. This acknowledgment is recorded electronically and maintained in your records in accordance with applicable law.