Financial Responsibility Agreement

Coastal Healthcare Advocates, LLC · Last updated:   to be dated on execution

Download this agreement as a printable PDF (opens in a new tab)

Parties

Coastal Healthcare Advocates, LLC, a Virginia limited liability company owned and operated by Lindsey Hewitt ("Advocate," "Coastal," "we," "us," or "our"), Virginia Beach, VA, serving clients nationwide. Phone: use our contact form (Monday–Friday, 8:00 AM–5:00 PM ET). Email: use our contact form.

Client:  

Financially Responsible Party (if different from the Client—for example, an adult child paying for a parent's advocacy services):

• Name:     Relationship to Client:  
• Address:  
• Phone:     Email:  

Effective Date:  

1. Purpose

This Financial Responsibility Agreement ("Agreement") sets out the fees, payment terms, and billing policies for the healthcare advocacy services described in the companion Client Service Agreement, executed together with this document. It applies whether the person paying for Services (the "Financially Responsible Party") is the same person receiving them or not.

2. Fee Structure

Coastal's fees are set out in Schedule A below. Most services carry a flat fee or a flat-fee range. Ongoing work that does not fit a flat fee is billed at the Standard Hourly Rate in 15-minute increments, and the Monthly Support Plan covers up to 5 hours a month for a fixed monthly fee. For balances over $5,000, the Client may choose the Savings-Based Fee described in Section 8 instead of hourly billing. Rates are starting points and may be adjusted for case complexity, the number of providers and insurers involved, and the time required; the fee for each service selected is agreed in writing in Schedule A before work begins.

If the Client's needs expand beyond the services selected in Schedule A, Coastal will discuss the additional scope and fee with the Financially Responsible Party in writing before beginning that additional work.

3. Schedule A—Fee Schedule

Fees are as published on the Coastal Healthcare Advocates pricing sheet dated October 17, 2026. Where a range is shown, the fee agreed for this engagement is written in the list that follows the table.

Services selected for this engagement (check all that apply):

• Medical Bill & EOB Review — $ 
• Insurance Claim Appeal — $ 
• Benefits Explanation Session — $75
• Provider Negotiation — $ 
• Single-Issue Package — $225
• Standard Hourly Rate — $110 / hour, estimated   hours
• Monthly Support Plan — $375 / month
• Savings-Based Fee — 10% of savings, capped at $  for   bills
• Flexible Payment plan — $50 plan fee,   months
• Other:   — $ 

Estimated total fee for this engagement: $  (see Section 4 for the down payment).

4. Down Payment and Payment Timing

A down payment of 25% of the estimated total fee is due upon signing this Agreement, before Coastal begins work on any paid service, and is credited in full toward the final bill. For savings-based cases, the $250 Case Minimum serves as the down payment and is credited toward the final fee in the same way. The estimated total fee and the down payment amount are recorded here and in the Client Service Agreement.

Estimated total fee: $ . Down payment (25%): $ , due upon signing. Remaining balance: $ .

The remaining balance is due as follows: for a flat-fee service, upon completion of that service; for hourly work, monthly, on invoice; for the Monthly Support Plan, in advance [confirm: at the start of each monthly period]; and for a savings-based case, as each bill or claim is resolved and its savings are confirmed in writing (Section 8). Invoices are due upon receipt unless otherwise agreed in writing. The Client may pay in full or as each bill or claim is resolved at no extra cost, or choose a payment plan of up to 12 months for a one-time $50 plan fee.

5. Payment Methods

Coastal accepts payment by [confirm: check, ACH / bank transfer, credit / debit card, other]. [confirm: is there a processing fee for card payments?]

6. Late Payment

A payment not received within 30 days of the invoice date is considered late. Coastal may suspend work on the Client's case until payment is received, and may charge a late fee of 1.5% per month (or the maximum allowed by Virginia law, if lower) on the overdue balance.

7. Refunds and Cancellation

The Client may cancel services at any time by written notice to Coastal. The Client is responsible for paying for all work completed up to the date of cancellation:

1. Hourly and savings-based work: at the agreed rate for the work done, and for a savings-based case, the Savings-Based Fee on any savings confirmed before cancellation.
2. Flat-fee services not yet completed: [confirm: pro rata, by the hours of work documented at the Standard Hourly Rate, up to the flat fee / the full flat fee once work has begun], because the fee reflects Coastal's professional time and expertise rather than a guaranteed result (Section 8).
3. Monthly Support Plan: monthly fees are [confirm: non-refundable once the month has begun / refundable on a prorated basis] if the engagement ends partway through a month.

Any portion of the down payment not yet earned under these terms will be refunded within a reasonable time after cancellation.

8. Fees and Outcomes

Flat fees, the Standard Hourly Rate, the Single-Issue Package, and the Monthly Support Plan are fees for professional services rendered and are not contingent on the outcome of any appeal, negotiation, or dispute. The Client owes those fees whether or not an appeal is approved, a bill is reduced, or a claim is resolved in the Client's favor, consistent with Section 4 (No Guaranteed Outcome) of the Client Service Agreement.

The Savings-Based Fee is the one exception, and applies only when the Client selects it in Schedule A for a balance over $5,000. Under it the Client pays 10% of the savings instead of hourly billing, capped at $3,000 for a case of up to 5 bills; the cap rises by $600 for each additional bill. "Savings" means the amount reduced, written off, or refunded, as confirmed in writing by the provider or insurer; a "bill" is one provider statement or one insurance claim. Savings-based fees are billed as each bill or claim is resolved and its savings are confirmed. The $250 Case Minimum is due when the case begins, is credited toward the final fee, and is owed regardless of the amount saved. Coastal does not guarantee any particular saving or outcome.

9. Fees Are the Client's Responsibility, Not Covered by Insurance

Coastal's advocacy fees are for Coastal's own services and are separate from, and not part of, any medical bill, insurance premium, or claim. Most healthcare advocacy services are not covered by health insurance, Medicare, or Medicaid, and these fees are paid directly by, and are the personal financial responsibility of, the Financially Responsible Party identified above, regardless of the outcome of any insurance matter Coastal assists with. [confirm: whether any HSA / FSA eligibility applies]

10. When the Financially Responsible Party Differs from the Client

Where a Financially Responsible Party is named above because they are paying on behalf of a Client or Service Recipient who is not the payer (for example, an adult child paying for a parent's advocacy services), both the Client and the Financially Responsible Party sign this Agreement, and the Financially Responsible Party is directly and personally liable for all fees described in Schedule A, independent of the Client's own resources or insurance coverage.

11. Billing Disputes

If the Client or Financially Responsible Party disputes a charge, they must notify Coastal in writing within [confirm: 15] days of the invoice or charge date, describing the basis for the dispute. Coastal will review and respond within [confirm: 10] business days. Undisputed portions of any invoice remain due per the terms above.

12. Entire Agreement; Governing Law

This Agreement, together with the Client Service Agreement, is the entire agreement between the parties regarding fees and payment for the Services, and supersedes any prior discussions or fee quotes not reflected in Schedule A. It is governed by the laws of the Commonwealth of Virginia. It may only be amended in writing signed by both parties.

13. Signatures

By signing below, each party agrees to the fees, payment terms, and policies in this Agreement, including Schedule A.

Return to the homepage