Common Contracts
2 similar Financial Responsibility Agreement contracts
Financial Responsibility AgreementFinancial Responsibility Agreement • October 21st, 2022
Responsibility. I understand I am responsible for all payment obligations arising out of my treatment and care and I guarantee payment for these services. At each visit, please be sure we have your current demographic and insurance information. It is your responsibility to provide us with this information, and update it if it changes. You will be responsible for any charges billed to the wrong insurance carrier as a result of not providing accurate insurance information. I understand I am responsible for any deductibles, co-payments, co-insurance or any other patient responsibility amounts indicated by my insurance carrier or for any services not covered by my insurance. We participate in most insurance plans, if your insurance is not a plan we participate in, you will be self-pay and payment plans are available.
Financial Responsibility AgreementFinancial Responsibility Agreement • October 21st, 2022
Responsibility. I understand I am responsible for all payment obligations arising out of my treatment and care and I guarantee payment for these services. At each visit, please be sure we have your current demographic and insurance information. It is your responsibility to provide us with this information, and update it if it changes. You will be responsible for any charges billed to the wrong insurance carrier as a result of not providing accurate insurance information. I understand I am responsible for any deductibles, co-payments, co-insurance or any other patient responsibility amounts indicated by my insurance carrier or for any services not covered by my insurance. We participate in most insurance plans, if your insurance is not a plan we participate in, you will be self-pay and payment plans are available.
