Common Contracts
3 similar Financial Responsibility Agreement contracts
FINANCIAL RESPONSIBILITY AGREEMENTFinancial Responsibility Agreement • July 28th, 2022
The patient is expected to present an insurance card at each visit. All co-payments and past due balances are due at time of check-in unless previous arrangements have been made with a billing coordinator. We accept cash, check or credit cards. Absolutely no post-dated checks will be accepted.
FINANCIAL RESPONSIBILITY AGREEMENTFinancial Responsibility Agreement • September 6th, 2016
The patient is expected to present an insurance card at each visit. All co-payments and past due balances are due at time of check-in unless previous arrangements have been made with a billing coordinator. We accept cash, check or credit cards. Absolutely no post-dated checks will be accepted.
FINANCIAL RESPONSIBILITY AGREEMENTFinancial Responsibility Agreement • July 26th, 2016
The patient is expected to present an insurance card at each visit. All co-payments and past due balances are due at time of check-in unless previous arrangements have been made with a billing coordinator. We accept cash, check or credit cards. Absolutely no post-dated checks will be accepted.
