Common Contracts
1 similar Patient Responsibility Agreement contracts
PATIENT RESPONSIBILITY AGREEMENT and INSURANCE POLICYPatient Responsibility Agreement • January 6th, 2017
We would like to take this opportunity to welcome you to our practice and assure you that we will do our utmost to provide you with the best possible care. Patients (parents) are requested to pay for services the day they are performed. Cash, check and credit cards are all accepted forms of payment. Diagnostics, like x-rays, and treatment are rendered based on standards of care adopted by the doctor. These may conflict with insurance frequencies for coverage or patient’s requested treatment desires. Ultimately, after discussion, treatment may be required to continue care. It is preferred that children 6 years and under, or those deemed by the doctor to benefit, are seen in the morning. Parents may accompany them into the treatment areas. In the afternoon, our office is attempting to set up for those children who have graduated to independent treatment with the doctor and clinicians.
