Common Contracts
2 similar Financial Agreement contracts
FINANCIAL AGREEMENT Patient/Client Name:Financial Agreement • December 30th, 2022
We will file claims to your medical insurance company for the services that are provided by our office. In order for the claims to process correctly, please ensure that the information that is provided to our office on the patient information form is accurate and current. If there is a change in insurance information please let us know immediately. We will submit to secondary insurance as long as we are given the correct information and we are notified that you would like this service done.
FINANCIAL AGREEMENT Patient/Client Name:Financial Agreement • January 2nd, 2022
We will file claims to your medical insurance company for the services that are provided by our office. In order for the claims to process correctly, please ensure that the information that is provided to our office on the patient information form is accurate and current. If there is a change in insurance information please let us know immediately. We will submit to secondary insurance as long as we are given the correct information and we are notified that you would like this service done.
