Financial Responsibility Agreement

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

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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 Hampton Roads and Southern Virginia. 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—Flat-Fee Packages

Coastal charges flat fees by service type, listed in Schedule A below, rather than hourly billing or a fee contingent on the outcome of an appeal, negotiation, or claim. The flat fee for a given service is due as described in Section 4, regardless of the ultimate outcome of that service (see Section 8, No Outcome-Based Fees).

If the Client's needs expand beyond the package(s) 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

[Populate from the current Coastal Healthcare Advocates pricing sheet—the service names below are placeholders based on the services described in the Client Service Agreement; adjust the list, and fill in the fee and description columns, to match the actual sheet.]

Package(s) selected for this engagement (check all that apply):

• Initial Consultation — $ 
• Insurance Eligibility & Benefits Verification — $ 
• Medical Billing & Coding Error Review — $ 
• Insurance Claim Denial Appeal — $ 
• Medical Bill Negotiation — $ 
• Ongoing Case Management — $  / month
• Other:   — $ 

Total due at signing: $ 

4. Deposit, Retainer, and Payment Timing

[confirm: deposit / retainer policy not yet decided]. Common approaches for flat-fee packages: full payment due at signing before work begins; a partial deposit (for example, 50%) at signing with the balance due on completion or delivery of the appeal or negotiation letter; or a monthly payment-in-advance structure for Ongoing Case Management. Whichever is chosen:

Payment of $ , representing [confirm: the full package fee / a deposit of ___%], is due upon signing this Agreement, before Coastal begins work. [if a deposit structure is used:] The remaining balance of $  is due [confirm: upon completion / delivery of the appeal letter / a specific date].

For Ongoing Case Management, the monthly fee is due in advance on the [confirm: 1st] of each month for that month's services.

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

[confirm] A payment not received within [confirm: 5 / 10] days of its due date is considered late. Coastal may suspend work on the Client's case until payment is received, and may charge a late fee of [confirm: a flat fee, for example $25, or a rate, for example 1.5% per month] on the overdue balance, to the extent permitted by Virginia law.

7. Refunds and Cancellation

[confirm: refund / cancellation policy not yet decided]. A typical structure for flat-fee advocacy work:

1. Before work begins: If the Client cancels before Coastal has begun any work on the selected package(s), Coastal will refund the amount paid, [confirm: in full / less a $___ administrative fee].
2. After work begins: Once Coastal has begun work (for example, reviewing records, drafting an appeal, contacting an insurer), the flat fee for that package is [confirm: fully earned and non-refundable / refundable on a prorated basis based on hours of work documented], because the fee reflects the value of Coastal's professional time and expertise rather than a guaranteed result (see Section 8).
3. Ongoing Case Management: Monthly fees are [confirm: non-refundable once the month has begun / refundable on a prorated basis] if the engagement ends partway through a month.

8. No Outcome-Based Fees

Coastal's fees are flat fees for professional services rendered, not a percentage of any savings, refund, or amount recovered, and are not contingent on the outcome of any appeal, negotiation, or dispute. The Client owes the applicable flat fee 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.

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. These fees are [confirm: generally not reimbursable by health insurance, Medicare, or Medicaid— confirm this is accurate and whether any exceptions apply, for example certain FSA / HSA eligibility] and are the personal financial responsibility of the Financially Responsible Party identified above, regardless of the outcome of any insurance matter Coastal assists with.

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.

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