Financial Policy

Chokmah Development & Consulting, Inc. has a contractual obligation with your insurance company to
collect copayments, deductibles, and/or coinsurance for all medically necessary services. If you have
questions regarding specific coverage issues, we suggest you contact your insurance company directly.
The phone number for the member services department is listed on the back of your insurance card.

This Financial Agreement is between Chokmah Development & Consulting, Inc. (the “Provider”), of
1486 W 84th Street, Hialeah, Florida 33014, and (the “Guarantor”), of
.

This Financial Agreement is entered into by and between the Provider and Guarantor and is subject to
the terms and conditions specified below.

Guarantor’s 202___ benefits under __________________________ (Policy #_______________):

• $__________ copayment per day

• $__________ Individual Deductible
• $__________ Individual Out of Pocket Maximum
All terms used, but not defined, herein shall have the meanings set forth in the original agreement.
Except as expressly set forth herein, the original agreement remains unamended and in full force and
effect.

I, _________________________, authorize Chokmah Development & Consulting, Inc. to charge my

credit card indicated below each Monday, beginning ____________________________, 202___, for
copayments owed to the Provider for medically necessary ABA services provided to
__________________ the preceding week until the $_________ out-of-pocket maximum is met.

Credit Card Number Exp. Date (mm/yy) Security Code

Name as it Appears on Card (Please Print) Billing Zip Code

Should the card on file be declined, the Provider will make a second attempt to charge the card. A $35
fee will be charged for declined payments if another form of payment is not provided within 72 hours of
notification of the declined payment. If a payment is declined a third time, the Provider may suspend
services until payment is made in full.

I acknowledge that I have reviewed and understand the information presented in this agreement.

IN WITNESS WHEREOF, the parties hereto have executed this Financial Agreement to be effective on
________________________, 202___.

By:
Dorinda Luzardo, for and on behalf of Date
Chokmah Development & Consulting, Inc.

By:
Parent/Guardian Printed Name

Parent/Guardian Printed Name Date

Child’s Name: Page 14 of 22