Common Contracts
1 similar Financial Agreement contracts
ContractFinancial Agreement • June 26th, 2012
Financial Agreement: I understand that I am responsible for deductibles, co-pays, non-covered services, coinsurance, and items considered “not medically necessary” by my insurance company. I agree to pay co-payments and coinsurances as services are rendered. I understand my insurance is a contract between myself and my insurance company and Eastern Shore Foot & Ankle Center. I understand that Eastern Shore Foot & Ankle Center will bill my insurance as a courtesy to me. The remaining balance will be taken care of within 30 days of notice from the insurance company. Although my insurance company may estimate what they may pay, it is the insurance company that makes the final determination. I agree to pay any portion of the charges not covered by insurance. If a referral and/or preauthorization are required by my insurance company, I will assist Eastern Shore Foot & Ankle Center in obtaining the referral and or preauthorization. If payment cannot be made at each visit, I will notify the f
