Guarantor Agreement NYC PSYCHOLOGY, PC/CENTER FOR ANXIETY LLC GUARANTOR AGREEMENTPatient Name:* First Patient DOB:* MM slash DD slash YYYY Guarantor’s Name:* First Guarantor's DOB:* MM slash DD slash YYYY Guarantor’s Email:* Guarantor’s Phone #:Guarantor’s Mailing Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country The Guarantor is financially responsible for services provided to the Patient by NYC Psychology PC/Center for Anxiety LLC (hereinafter “NYCP/CFA”). The following terms are mutually agreed upon: NYCP/CFA does not accept insurance and is a private pay facility. Guarantor will unconditionally cover all financial obligations of the Patient to NYCP/CFA. Guarantor will promptly pay for all amounts billed in connection with all services provided to the Patient, upon receipt. If payment is not received within ten (10) days following billing, NYCP/CFA may terminate all patient services and cancel all scheduled appointments. If payment is not received within thirty (30) days following billing, a late fee of 1% of the balance owing will be charged. If payment is not received within sixty (60) days, accounts will be considered in default and turned over to collections. Guarantor agrees to pay all costs incurred by NYCP/CFA in the event of a late payment or default, including reasonable attorney fees associated with collections. Guarantor acknowledges the NYCP/CFA cancellation policy: If Patient needs to cancel or reschedule an appointment, Patient must contact our office at least one (1) business day in advance. Payment will be due in full for sessions that are missed without provision of one (1) business days’ notice. Guarantor will be charged a $100 fee for any check that is returned unpaid, whether or not it can be resubmitted for payment. The terms of this agreement are ongoing and cannot be voided due to changes in legal circumstance, health insurance, or termination of services with NYCP/CFA when there is any remaining balance, without consent by both parties (Guarantor and NYCP/CFA) in writing. There are no understandings, representations, or agreements, between the Guarantor and NYCP/CFA relating to payment, which are not contained in this agreement. Guarantor must inform NYCP/CFA of any contact information or address changes. This agreement shall be construed and enforced according to the laws of the within state the treatment is being provided. Guarantor consents to the jurisdiction of the state the treatment is provided in the event of legal proceedings. Guarantor’s Signature:*Date* MM slash DD slash YYYY CAPTCHA
