you will be treated as a self-pay patient and must make payment at the time of service.

By signing below, you agree to accept full financial responsibility as a Patient who is receiving medical services, or as the Responsible Party. Your signature verifies that you have read this Patient Financial Responsibility statement, understand your responsibilities, and agree to these terms.

Patient Statement of Financial Responsibility o I understand and agree that my co-payment, co -insurance and deductibles are due and payable at the time of service , and I may

I hereby authorize any insurance carrier, including Medicare, to make payment directly to Allied Digestive Health for any services rendered to me or my covered dependents of any amounts otherwise payable to me toward the reimbursement of any medical