Common Contracts
1 similar Financial Policy and Patient Agreement contracts
FINANCIAL POLICY AND PATIENT AGREEMENTFinancial Policy and Patient Agreement • May 9th, 2020
The patient also authorizes the exchange of information relating to care and claims with the patient’s insurance companies, its intermediaries, carriers, referring physician, and primary care physicians. The patient authorizes insurance payments to be made directly to the Practice for services provided. Payment by the insurance company sent straight to the patient must be reimbursed by the patient to the Practice. By signing below, I authorize and consent to examination, treatments, and procedures, which, by the assessment of my physician, may be considered necessary or advisable for diagnosis or treatment of my case. Regardless of if my insurance pays for the services, I understand I am financially responsible. I authorize any credit amounts, irrespective of the date paid, applied to any balance due on my account.
