ultimately responsibile for your account:
Card Type: Visa
Credit Card Number:
invite you to discuss with us any questions regarding
our services. The best health services are based on a
friendly, mutual understanding between providor and patient.
policy requires payment in full for all services rendered
at the time of the visit, unless other arrangements have
been made with the business manager. If your account has
not been paid within 90 days of the date of service and
no financial arrangements have been made, you will be
responsible for legal fees, collection agency fees, and
any other expenses incurred in collecting your account.
submitting this form you agree to authorize the staff
to perform any services needed during diagnosis and treatment.
You also hereby authorize the provider and or managed
care organization to release any information required
to process your insurance claims.
submitting this form you guarantee that it was completed
correctly to the best of your knowledge and that you understand
that it is your responsibility to inform this office of
any changes to the information you have provided.