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PATIENT RESPONSIBILITY FORM 1. INDIVIDUAL’S FINANIAL RESPONSIILITY I understand that I am financially responsible for my health insurance deductible, coinsurance or non …

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.

Understanding your insurance plan and benefits is the patient's responsibility: any deductibles, co-insurance, or co-payment amounts are due at the time of the visit. You may have diferent …

This Patient Financial Responsibility Form will complement and be incorporated into the Practice’s existing Patient Agreements and Acknowledgements signed by me.

hereby assign and authorize payment directly to the Clinic of all medical benefits under any insurance or third party plan payable to me or which I am otherwise entitled.

*This form is utilized after the patient has been provided with the notification of financial assistance and charity care program.

Patients are responsible for payment of co-pays, co-insurance, deductibles, and all other procedures or treatment not covered by their insurance plan. Copays are due at the time of …

Patient Name: (Patient Label) Dear Patient, Due to increasing complexity in the healthcare industry, it is important for us to understand the precise nature of your doctor visit today. …

It is the patient’s responsibility to know if their insurance has specific rules or regulations, such as the need for referrals, pre-certifications, pre-authorizations, and limits on outpatient charges …

We will provide you with a statement that you can submit to your insurance company for reimbursement. Proof of payment and photo ID are required for all patients. We will ask to …