Camp and Group Services: Self-Pay Agreement Form
As the parent/guardian of the patient noted below, I authorize Cortica to provide and invoice the following programs. I understand this is a self-pay service not covered by my insurance.
I understand the volume-discounted rates are:
I also understand that payment will be due at the time of service. Payments can be made with the front office administrator or by contacting our billing department at billing@corticacare.com.
Patient Name:
Patient DOB:
Guardian Name:
Signature: Date: