Article 6: Retroactive Effect: If the patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), the patient should initial here.initial. Effective as of the date of first professional services.
By signing below, I confirm the amount of payment made by me, and I understand that the payment (or no payment) is an estimate of my financial responsibility for the service rendered today. My final responsibility is based on the Explanation of Benefits. Any under-collection will be billed to me. Over-collection is refunded to me quarterly.
Agreed by signing below