Common Contracts
2 similar Patient Payment Agreement contracts
PATIENT PAYMENT AGREEMENTPatient Payment Agreement • January 26th, 2022
This is the remaining balance for dates of service on or before this date which insurance has paid or which is not covered by insurance. Any balance due from charges yet to be paid by insurance will be added to this balance. I understand that this balance is my responsibility and may change if I incur future charges for service rendered after this date.
PATIENT PAYMENT AGREEMENTPatient Payment Agreement • February 18th, 2021
This is the remaining balance for dates of service on or before this date which insurance has paid or which is not covered by insurance. Any balance due from charges yet to be paid by insurance will be added to this balance. I understand that this balance is my responsibility and may change if I incur future charges for service rendered after this date.
