Forms Completion. Forms may be dropped off and we will call when they are ready to be picked, or we will send to appropriate designee. Fees for form completion are as follows: $15.00 for Affidavit $8.00 for films/photos $18.00 for Government/Disability forms 6. RESPONSIBILITY FOR PAYMENT: I understand that I, personally, am financially responsible to Ophthalmology Associates for charges not covered by the assignment of insurance benefits and all non-covered charges.
Appears in 4 contracts
Samples: Patient Financial Agreement, Patient Financial Agreement, Patient Financial Agreement
