Common Contracts
1 similar Patient Financial Responsibility Agreement contracts
NEUROFEEDBACK PROGRAM PATIENT FINANCIAL RESPONSIBILITY AGREEMENTPatient Financial Responsibility Agreement • November 5th, 2019
Thank you for choosing Neurological Specialists, P.C. as your healthcare provider. The Neurofeedback Program (“Services”) you seek imply a financial responsibility on your part. This responsibility obligates you to ensure payment in full for the Services that you receive. To assist in understanding that financial responsibility, we ask that you read and sign this form. By signing below and/or by receiving medical Services from Neurological Specialists, P.C. (“Neurological Specialists”), you agree to the following:
