Insurance Client Form Who is signing?*I am signing for myself.I am signing for a minor.Your name (PATIENT) First Last Minor Patient's Name First Last Consent I agree to the ELECTRONIC SIGNATURE CONSENTI understand that by agreeing to the Electronic Signature Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement. I further agree my signature on this document is as valid as if I signed the document in writing. This is to be used in conjunction with the use of electronic signatures on all forms regarding any and all future documentation with a signature requirement, should I elect to have signed electronically. Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.Consent I agree to FINANCIAL RESPONSIBILITY CONTRACTThis Financial Responsibility Contract (“Contract”) is entered into between PATIENT (“Patient”) and CAMBIATI WELLNESS, LLC (“Cambiati Wellness”). Purpose: The purpose of this Contract is to establish the financial responsibility of the Patient for healthcare services received from Cambiati Wellness, and to outline the terms of payment and insurance coverage. Insurance Coverage: The Patient agrees to provide accurate and complete insurance information to Cambiati Wellness, including but not limited to insurance policy numbers, insurance company name and contact information, and any other necessary information required to file an insurance claim. Payment Obligation: The Patient agrees to be financially responsible for any healthcare services received from Cambiati Wellness, including but not limited to co-payments, deductibles, and any other out-of-pocket expenses not covered by insurance. Authorization for Payment: The Patient authorizes Cambiati Wellness to file insurance claims on their behalf and to receive payment directly from the insurance company for services rendered. Discrepancies in Coverage: While Cambiati Wellness has called your insurance company and has made every attempt to verify coverage, Cambiati Wellness cannot be held responsible for errors made by the insurance company. In the event that there is a discrepancy in the coverage, you will be responsible for any copay, co-insurance or unforeseen fees not covered. We will support you in addressing any errors with the insurance company, including providing information about when and with whom the information was verified. Collection Efforts: If the Patient fails to make payment on a balance due, Cambiati Wellness may take appropriate collection efforts, including but not limited to sending the account to collections, reporting the debt to credit reporting agencies, and pursuing legal action. Amendments: This Contract may be amended by Cambiati Wellness at any time, provided that the Patient is given written notice of any changes to the terms and conditions of this Contract. Governing Law: This Contract shall be governed by the laws in California. Entire Agreement: This Contract constitutes the entire agreement between the parties and supersedes all prior agreements, whether written or oral, relating to the subject matter of this Contract. Signature – Use the mouse or your finger if you have a touch screen.PhoneThis field is for validation purposes and should be left unchanged.