Simply Grace (SG) Out Patient Responsible Party Agreement

 

(Revised 09/28/2018)

 

This agreement is between, the following parties as so identified for this agreement:

 

Simply Grace (a 501C3 Charitable Organization) is the provider of substance services to the Client identified below. (Hereinafter referred to as “SG”).

 

The responsible party whose name is set forth below agrees to be responsible for all the financial obligations of the Client identified below relating to the services provided by SG. (Hereinafter referred to as “responsible party”)

 

The client receiving the benefits of the services provided by Simply Grace is identified below as the “client” and shall hereinafter be referred to as “client”.

 

SG agrees to provide to client services more particularly described as substance abuse services under the terms and conditions set forth herein below:

 

  1. Responsible party shall pay for all services being performed by SG at the time of delivery of the service or upon receipt of any invoice submitted by SG to responsible party.

 

  1. Responsible party understands that SG is providing said services to client in part because of responsible parties’ agreement to pay for the services being provided to Client.

 

  1. Responsible party shall pay for the services being performed by SG in accord with the published fee schedule. The fee schedule may change from time to time with notice to responsible party. Said notice shall be in writing and shall be sent to responsible party’s last known address by regular mail, certified mail or by email. Any fee schedule changes shall become effective as of thirty (30) days from the date of sending the notice called for herein.

 

  1. Responsible Party understands and agrees that this is a continuing guarantee of payment for all substance abuse services provided to client regardless of whether the services provided to client are performed consecutively or intermittent, as in the case of client leaving the program and returning at a later date. This continuing guarantee of payment shall continue until all services provided to client are paid in full.

 

  1. Any service not paid for in accord with the terms herein shall be considered delinquent. All paid fees charged are non-refundable, irrevocable, and not dependent on the outcome of the services being provided to Client. If client’s account becomes delinquent for any reason, SG is authorized to add any additional fees that may be incurred to collect the account, including but not limited to, bank incurred bad check fees, attorney fees, collection agency fees, mail and postage fees, and copying fees. SG may charge and collect a late fee of up to five percent (5%) of any amount due that delinquent, to the extent not prohibited by law. SG may charge interest on any delinquent amount at the rate of eighteen percent per annum from the date of delinquency until paid in full.

 

  1. It is acknowledged that the responsible party may not be the client. Under said circumstance, responsible party shall only be considered a guarantor of the services provided to client. Said guaranty shall be irrevocable, absolute, completed and a continuing guaranty of payment and performance and not a guaranty of collection, and shall not be affected by the release or discharge of client from, or impairment or modification of, client’s obligations with respect to the account or charges for services. Further, this guaranty shall be continuing regardless of client’s length of stay in a SG program, interruption of a SG program or if the client’s enrollment in a SG program is at different times. The fact that invoices may be rearranged, increased, reduced, extended for any period and/or renewed from time to time shall not release, discharge or reduce the obligation of responsible party with respect to the payment for the services to client, and responsible party shall remain fully bound hereunder.

 

  1. It is understood that “SG” does accept insurance for specific Out Patient services and that Responsible party and client are responsible for payment of any non-covered services, unmet deductibles, out of pocket or additional fees for services provided which may not be reflected on the published Fee Schedule.

 

  1. Responsible party acknowledges that should it become necessary to seek collection of the amounts that are agreed to herein, whether through the services of an attorney or a collection agency, the cost of those collection services will be added to the past due balance. Further, should SG be required to file suit for collection of the amounts that are due herein, the reasonable and necessary cost of said attorney services, shall be added to the amount of any past due amount being collected.

 

  1. Responsible party is simply a guarantor of payment and SG is not providing any warranties, representations or commitments to Responsible party concerning the response of client to the services, the success of the treatment to client, or anything else relating to the performance of services by SG. Responsible party acknowledges and waives any express or implied warranties regarding the services being performed and understands that each client responds differently. Responsible party further agrees that there are no guarantees that client will respond to the services provided by “SG”, or will stop using drugs or alcohol, or will stop breaking the law or change in any way. Responsible party understands that the success of the program is based upon the client’s willingness to change, get honest, take responsibility and seek a new way to live. As such, the responsible party waives any and all claims based in tort, contract, deceptive trade practices, statutory claims or claims based upon common law negligence or medical negligence. This waiver is unconditional and specific as to the services being provided to client. SG shall not be required to seek collection from the client before attempting collection from the responsible party.

 

  1. If responsible party and the client is the same person or if client signs this agreement in addition to the responsible party, all references to responsible party shall be considered a reference to the client.

 

  1. If responsible party and client are each signing this agreement, they shall be jointly and severally liable for any amounts due herein. The undersigned waive any requirement of trial by jury for any dispute and at the sole election of SG. This waiver is unconditional and for the benefit of SG.

 

  1. This agreement cannot be modified except in writing agreed to by SG. No oral modifications shall be acceptable. All modifications must be agreed to and signed by an authorized agent of SG to become effective. Further, any discussion, whether in writing or oral prior to the execution of this agreement, shall be considered merged into this agreement and any term, condition or statement made prior to the execution of this agreement shall be of no further force or effect.

 

This agreement is executed by the undersigned in Dallas County, Texas and Collin County, Texas. Dallas County, Texas and Collin County, Texas shall be place of payment, and performance of the services to client. Any dispute between the parties concerning this agreement or treatment to the client shall be filed in a state court in Dallas County, Texas and Collin county, Texas with Texas state law as the choice of law. By checking this box you agree to the terms and conditions of the Simply Grace (SG) can provide services to the resident. You are advised that if you feel uncomfortable or uneasy with the agreement, you should have it reviewed by an attorney prior to checking the box.