Common Contracts
1 similar Privacy and Consent Agreements contracts
Privacy and Consent AgreementsPrivacy and Consent Agreements • March 3rd, 2011
My Payment Responsibility : I understand that my co-payment, my co-insurance, or deductible is due at the time of medical service . I understand all non-covered items and charges are my financial responsibility . Any amount not covered by my insurance company, is due within 30 days of the appointment. Any late payment will incur a $15.00 fee. If I do not make payment or payment arrangements with the practice by the due date, in additional to the late fee, I will be sent to collections and I may be subject to dismissal from the practice.
