Common Contracts
1 similar Patient Financial Responsibility Agreement contracts
Patient Financial Responsibility AgreementPatient Financial Responsibility Agreement • January 7th, 2022
Your signature below forms a binding agreement between, on the one hand, Allergy Asthma Medical Associates, LTD. dba Relief Allergy & Sinus Institute (the “Practice”) and, on the other hand, the undersigned Patient who is receiving medical services or the undersigned Responsible Party for patients under 18 years old or holding other legal representative status. The Responsible Party is the individual who is financially responsible for payment of medical bills. This includes all fees for medical visits, procedures, and tele-health communications.
