Common Contracts
1 similar Patient Financial Responsibility Agreement contracts
PATIENT FINANCIAL RESPONSIBILITY AGREEMENTPatient Financial Responsibility Agreement • April 12th, 2022
Thank you for choosing Psychiatric, Health & Wellness (PHW) LLC as your healthcare provider. The medical services you seek imply an obligation on your part to ensure payment is made in full for services received. The Patient Financial
PATIENT FINANCIAL RESPONSIBILITY AGREEMENTPatient Financial Responsibility Agreement • June 23rd, 2021
Thank you for choosing Psychiatric, Health & Wellness (PHW) LLC as your healthcare provider. The medical services you seek imply an obligation on your part to ensure payment is made in full for services received. The Patient Financial Responsibility Agreement (“Agreement”) will assist you in understanding your financial responsibility. Feel free to ask questions. If someone else (parent, spouse, domestic partner, etc.) is financially responsible for your expenses, please share this Statement with them, as it explains to our practice financial policy. The financially responsible person signing this agreement must be eighteen (18) years or older and be employed.
