Common Contracts
1 similar Outpatient Services Contract contracts
OUTPATIENT SERVICES CONTRACTOutpatient Services Contract • August 13th, 2018
Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them. When you sign this document, it will represent an agreement between us and consent to treatment. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action which relied on the Agreement; if there are obligations imposed on me by your health insurer or in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations. In addition, if I make any changes to my business policies I will provide you with written notification of these changes prior to their implementation. I will ask you to sign a form to acknowledge receipt of such a notification at that time.
