Price: $15.00
Format: Editable PDF | 1 Page | Instant DownloadDescription: This clear, professional form documents when a parent, spouse, or other responsible party agrees to cover the financial costs of a client’s care. Designed to prevent billing confusion and ensure payment accountability, it includes required authorization language for card-on-file and automatic payment consent.
Includes:
- Responsible party acknowledgment and relationship to client
- Card-on-file and automatic charge authorization
- Optional client co-signature field
- HIPAA-compliant financial consent section
- Editable PDF format with GBBS branding
Perfect for:
Therapists, psychiatrists, and group practices wanting a clear, compliant way to document client agreement to payment terms.
* Created by Golden Bee Billing Services, LLC — experts in behavioral health billing, compliance, and operational design.
Taxes included in price.
Third Party Financial Responsibility Agreement (2025 Edition)
© 2025 Golden Bee Billing Services, LLC
All rights reserved. This document is an original work created by Golden Bee Billing Services, LLC and may not be copied, resold, or distributed without written permission.This template is intended for informational and administrative use only. It does not constitute legal advice and should be reviewed or customized to fit your individual practice policies and state regulations before use.
Licensing Your purchase includes a single-use commercial license for use within one private practice. You may print, fill, and digitally store the form for client use within your practice, but redistribution, resale, or reproduction for others is not permitted.
Pricing Note All prices listed in The Hive Shop include applicable taxes. No additional fees will be added at checkout.