PATIENT FINANCIAL RESPONSIBILITY ACKNOWLEDGEMENT

Family Tree Medical Clinic

2508 NW Medical Park Drive

Roseburg, OR 97471

541-673-5225
PATIENT FINANCIAL RESPONSIBILITY ACKNOWLEDGEMENT
Full Name*
Date of Birth*

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Date
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Primary Phone*
Secondary Phone
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Email
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Address*

Mailing Address

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Primary Insurance Name*
ID Number*
Group Number (If Applicable)
Secondary Insurance Name
ID Number
Group Number (If Applicable)
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BECAUSE THERE ARE IMMEDIATE EXPENSES TO PROVIDE A SERVICE TO OUR PATIENTS, WE EXPECT YOU TO CONTRIBUTE YOUR PORTION WHEN APPLICABLE. THE FOLLOWING FORMS OF PAYMENT ARE REQUIRED.

INSURANCE: We will bill your insurance as a courtesy.
CO-PAYMENTS: Due each office visit prior to seeing the provider.
Initial*
CO-INSURANCE: Applicable percentage amount will be collected at the time of service. Our office staff will do their best to collect the exact amount owed; however, there may be a small credit or an additional amount due after insurance processing.
Initial*
DEDUCTIBLES: If you have a high deductible plan we may ask you to pay towards your visit prior to seeing the provider
Initial*
SELF PAY: Due in full at the time of service.
PATIENT RESPONSIBILITY: Patient balance responsibility beyond insurance, are due within 30 days of the statement bill.
NON-COVERED SERVICES: Non-covered services are the responsibility of the patient/guardian. Non-covered services vary from each insurance company. These may include, but are not limited to, health physicals, laboratory tests, Procedures, and injections.
LATE CHARGE: We reserve the right to impose, and you agree to pay, a late charge of 1.5 percent per month for any balance that remains outstanding 90 days after the date of service.
Initial*
APPOINTMENT CANCELLATION: A 24-hour notice of appointment cancellation is required otherwise a $25.00 fee will be charged and your account marked as "no show". We reserve the right to discharge entire families with 3 "no shows" per family.
Initial*
I have read the above office payment policy and as a patient, or legal guardian of a minor or impaired patient, I understand that regardless of any insurance coverage I may have, I am responsible for payment of my account. I understand there is no interest or finance charge on current accounts. However, I am also aware that delinquent accounts beyond 90 days are subject to other collection means at my own expense and no further appointments will be scheduled until my account is paid in full unless prior arrangements have been made. I understand I may request a payment plan if necessary to keep my account in good standings.

I have read, understand, and agree to the above office payment policy in accordance with the terms and conditions set forth in the policy of this office. I also hereby attest that I have given payment information to the best of my knowledge for complete and timely payment.
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Date*

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Date
Printed Name*
Patient Name if different
Family Tree Medical Clinic reserves the right to revise this agreement at any time with or without your consent. Last Revised: 12/31/2024
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