Common Contracts
2 similar Patient Financial Agreement contracts
HEALTH FIRST COLORADO PATIENT FINANCIAL AGREEMENT AND GUARANTEEPatient Financial Agreement • November 3rd, 2021
I, the undersigned, acknowledge that not all services provided to me by Endocrinology Specialists of Colorado, LLC (“Provider”) are covered or reimbursable by my insurance plan, including Colorado’s medical assistance program, the Health First Colorado Medicaid Plan (the “Plan”). I acknowledge and accept that I am financially responsible for all services and items rendered on my behalf by the Provider by which a charge may be associated and which is not covered and/or not reimbursable. I agree to give the Provider complete and accurate insurance information for primary and secondary insurance coverage and all identification and benefit cards/ documents required for claim accuracy.
HEALTH FIRST COLORADO PATIENT FINANCIAL AGREEMENT AND GUARANTEEPatient Financial Agreement • August 17th, 2021
I, the undersigned, acknowledge that not all services provided to me by Endocrinology Specialists of Colorado, LLC (“Provider”) are covered or reimbursable by my insurance plan, including Colorado’s medical assistance program, the Health First Colorado Medicaid Plan (the “Plan”). I acknowledge and accept that I am financially responsible for all services and items rendered on my behalf by the Provider by which a charge may be associated and which is not covered and/or not reimbursable. I agree to give the Provider complete and accurate insurance information for primary and secondary insurance coverage and all identification and benefit cards/ documents required for claim accuracy.
