Common Contracts
1 similar Patient Financial Responsibility Agreement contracts
PATIENT FINANCIAL RESPONSIBILITY AGREEMENTPatient Financial Responsibility Agreement • August 19th, 2023
Thank you for choosing Connecticut Colon & Rectal Surgery, LLC as your healthcare provider. The medical services you seek entails a financial responsibility on your part. This responsibility obligates you to ensure payment in full for the services you receive. To assist in understanding that financial responsibility, we ask that you read and sign this form. Feel free to ask if you have any questions regarding your financial responsibility. If someone else (parent, spouse, domestic partner, etc.) is financially responsible for your expenses or carries your insurance, please share this policy with them, as it explains our practices regarding insurance billing, co- payments, and patient billing. By signing below and/or by receiving medical services from Connecticut Colon & Rectal Surgery, LLC you agree:
