Common Contracts
1 similar Office Policy Agreement contracts
Dr. Nancy Aria - Office Policy Agreement FormOffice Policy Agreement • January 16th, 2019
• (initials) I understand that it is my responsibility to provide the doctor with my current and accurate insurance card and a valid referral, if required by my insurance, at the time services are rendered. If I cannot provide my current insurance card and/or referral, my appointment may be rescheduled. Claims that are denied for payment because of incorrect insurance information will become the responsibility of the patient.
