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Patient Consent & Financial Responsibility Form

  • Date Format: MM slash DD slash YYYY
  • INDIVIDUAL RESPONSIBLE FOR PAYMENT OF UNPAID BALANCES
  • NAMERELATIONSHIPPHONE NUMBER 
  • PRIMARY INSURANCE HOLDER’S INFORMATION
    *ALL PATIENT INFORMATION IS STRICTLY CONFIDENTIAL. YOUR INFORMATION IS NEVER SHARED
  • Date Format: MM slash DD slash YYYY
  • Please initial the three statements below.

  • IN THE EVENT THAT THE SPONSOR OF YOUR INSURANCE PLAN DETERMINES THAT YOU ARE NOT ELIGIBLE AT THE TIME OF SERVICE OR MAKES A DETERMINATION THAT YOU ARE ELIGIBLE FOR A REDUCED LEVEL OF COVERAGE, BY SIGNING THIS AGREEMENT YOU AGREE TO BE FINANCIALLY RESPONSIBLE FOR ANY AND ALL OF THE CHARGES INCURRED BY YOURSELF AND THE PLAN SPONSOR.