Fees and Signature By submission of this request for reimbursement, the undersigned represents that services have been performed as described on dates and times specified. The undersigned agrees to maintain clinical notes for those services. The undersigned agrees
to submit this form no more than two weeks after the last date of service. The
undersigned agrees to a fee reduction based on late submission as follow: Submissions between 91 and 120 days after last date of service produces 50% of contracted rates. Submissions 121 days after last date of service forfeits payment. The undersigned agrees not to seek reimbursement for any services from any payor (including the client and/or any insurer) other than HDC.