Common Contracts
1 similar Patient Financial Responsibility Agreement contracts
Patient Financial Responsibility Agreement-Patient Financial Responsibility Agreement • May 11th, 2013
• As a courtesy to you, we will gladly bill your insurance for services however, you, the patient, have a contract with your insurance carrier. We cannot guarantee that your insurance will cover our services. You are required to present your current insurance card and picture ID at the front desk at each visit so we can verify your current information. Please inform us of any and all insurance you possess, and of any recent changes. All charges are ultimately your responsibility, regardless of insurance coverage or payment problems. You are responsible for payment of any and all copayments, deductibles, coinsurance and out-of-pocket expenses incurred, including fees for services not covered under your insurance policy.
