Acknowledgement of Financial Responsibility

This Acknowledgement of Financial Responsibility (“Acknowledgement”) is intended to provide patients with an understanding of their financial responsibilities should they elect to self-pay for behavioral health services provided by a professional corporation or other legal professional entity associated with Therapymatch, Inc. d/b/a Headway (“Headway”) prior to the date of service.

By agreeing to these terms, I (either as the patient listed below on behalf of myself or, if applicable, on behalf of a person I am authorized to sign on behalf of), understand and agree that:

1. I am not currently enrolled in or eligible for Medicare or Medicaid.
2. I am not seeking treatment from Headway for a work-related injury or for assistance with disability paperwork.
3. One of the following statements applies to my situation:
   1. I have health insurance coverage; however, Headway does not currently accept my health insurance plan.
   2. Headway accepts my health insurance plan, which may cover some or all of the services rendered to me by Headway; however, I am instructing Headway not to submit claims to my health insurance plan and agree to forgo the ability to submit claims to my health insurance plan directly for services rendered to me.
   3. I do not currently have health insurance coverage.
4. I elect to cover the full cost for all services I receive from Headway. If I am signing as an authorized representative on behalf of another person, I agree to be responsible for payment.

Further, I agree to:

1. Pay Headway for services rendered at the time of my visit.
2. Provide Headway with a valid payment card to be kept on file and authorize Headway to charge my payment card for services rendered at the time of service, subject to the Supplemental Headway Payment Terms (available at https://headway.co/legal/payment). If I have elected to facilitate payment to my provider off of the Headway platform, this provision does not apply.
3. Notify Headway by contacting support or messaging my provider if I no longer wish to self-pay for the services and provide Headway with third-party payment information (i.e., health play or other third-party payor) as appropriate. This change in financial information will become effective upon the receipt by Headway and will not apply to services rendered to me prior to that date.

I certify that I have read and understand the terms of this Acknowledgement and agree to be bound by its terms.