Common Contracts
2 similar null contracts
ContractJanuary 30th, 2018
Modesto Pediatrics Financial Agreement and Consent (2018) We are committed to providing your family with the best possible pediatric care. Your signature at the end of this document will indicate that you have read, understand and agree to the policies outlined below. UPDATE YOUR CONTACT INFORMATION: We depend on accurate information for emergency contact and for billing. If you move, or change your telephone number please inform the front desk so we can update our data base. BILLING YOUR INSURANCE: • Please present your current health insurance card at each office visit. • If you have No Insurance then payment in full is required at the time of service. • Our office will bill validated insurance as a courtesy. You must pay for any patient responsibility. • Know your insurance and REMEMBER: Non-covered services such as vaccines can be VERY EXPENSIVE. PAYMENT FOR SERVICES: • Co-pays MUST be paid at the time of service. • We accept cash, checks, money orders, Visa, MasterCard and debit c
ContractJanuary 19th, 2017
Modesto Pediatrics Financial Agreement and Consent (2017) We are committed to providing your family with the best possible pediatric care. Your signature at the end of this document will indicate that you have read, understand and agree to the policies outlined below. UPDATE YOUR CONTACT INFORMATION: We depend on accurate information for emergency contact and for billing. If you move, or change your telephone number please inform the front desk so we can update our data base. BILLING YOUR INSURANCE: • Please present your current health insurance card at each office visit. • If you have No Insurance then payment in full is required at the time of service. • Our office will bill validated insurance as a courtesy. You must pay for any patient responsibility. • Know your insurance and REMEMBER: Non-covered services such as vaccines can be VERY EXPENSIVE. PAYMENT FOR SERVICES: • Co-pays MUST be paid at the time of service. • We accept cash, checks, money orders, Visa, MasterCard and debit c
