oviedokids.com - Patient Responsibility Form

Patient Financial Responsibility
Patient Name:
DOB:

MonthDayYear
Date
- Our staff will ask you for payment for any past due balances as well as your portion of the payment for today’s service.
- Payment is expected at time of service. This includes all co-payments, co-insurances and deductibles.
- I understand that I am financially responsible for my health insurance deductible, coinsurance or non-covered service.
- In the event that my health plan determines a service(s) to be “not payable” I will be responsible for the complete charge and agree to pay the costs of all services provided.
- In the event that my health plan determines an immunization(s) to be “not payable” I will be responsible for the complete charge and agree to pay the costs of all immunization(s) provided.
- If I am uninsured, I agree to pay for the medical services rendered to me at time of service.
By Signing below, I acknowledge I understand the Patient Financial Responsibility outlined above.
Date:

MonthDayYear
Date
Printed Name of Responsible Party:
Signature of Responsible Party:

Clear
Relationship to Patient:
Should be Empty: