Common Contracts
1 similar Patient Financial Responsibility Agreement contracts
PATIENT FINANCIAL RESPONSIBILITY AGREEMENTPatient Financial Responsibility Agreement • December 7th, 2023
Insurance Claims/Payment: As a courtesy, Reis Pediatrics will file your insurance claims for you; however, in the event that your insurance company denies payment for any reason or has not paid within 90 days, the parent(s) and/or guarantor will be responsible for any balance due. It is also the parent(s) and/or guarantor’s responsibility to provide current insurance information, including the insurance subscriber number and mailing address, and to follow up on any benefit questions with the insurance carrier. You are responsible for informing Reis Pediatrics of changes in insurance coverage within 30 days from the date of service, you may be responsible for any charges incurred due to delay in timely submission of charges. We must emphasize that we are a medical care provider; our relationship is with the patient and not the insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the servic
