Common Contracts
1 similar Patient Responsibility Agreement contracts
MEMBER/PATIENT RESPONSIBILITY AGREEMENTPatient Responsibility Agreement • May 22nd, 2012
Participating health care professionals/facilities ("Providers") are prohibited from charging members for any service, product or upgrade (collectively, "Service") that is deemed not medically necessary, unless the member specifically requests such Service and agrees in writing to be financially responsible for It. This waiver form shall be used to document the Member's agreement to be responsible for such Services, To be effective and valid, this document must be executed prior to the delivery of any non-medically necessary Service.
