Common Contracts
2 similar Patient Waiver Policy & Agreement contracts
Atlanta Center for Reconstructive Foot & Ankle Surgery, LLC (Atlanta) Patient Waiver Policy & AgreementPatient Waiver Policy & Agreement • March 9th, 2017
In consideration of my particular medical needs and care expenses incurred solely based on such medical needs, and my financial ability to pay for such recommended medical services without or even with applicable insurance coverage, and with understanding that I am personally financially responsible for any and all medical charges regardless of any applicable insurance coverage, I hereby declare that I have financial difficulty to pay for part or all expenses because of the following:
Atlanta Center for Reconstructive Foot & Ankle Surgery, LLC (Atlanta) Patient Waiver Policy & AgreementPatient Waiver Policy & Agreement • March 9th, 2017
In consideration of my particular medical needs and care expenses incurred solely based on such medical needs, and my financial ability to pay for such recommended medical services without or even with applicable insurance coverage, and with understanding that I am personally financially responsible for any and all medical charges regardless of any applicable insurance coverage, I hereby declare that I have financial difficulty to pay for part or all expenses because of the following:
