Patient Financial Responsibility

Patient Financial Responsibility
Date

MonthDayYear
Date
Name

First NameLast Name
- I understand that I am financially responsible for my health insurance deductible, coinsurance, or non-covered service.
- If my plan requires a referral, I must obtain it prior to my visit.
- In the event that my health plan determines a service to be "not payable", I will be responsible for complete charges and agree to pay the cost of all services provided.
- If I am uninsured, I agree to pay for the medical services rendered to me within 1 month of invoice date.
Signature

Clear
Our office will do our best to help you understand your insurance benefits or policy, if you wish, however this is not a guarantee of payment.
Signature

Clear
Should be Empty: