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Available Forms

Financial Responsibility Agreement HIPAA Form Medical History Record Form Welcome To Our Office Form

Financial Responsibility Agreement

Insurance is NOT a guarantee, it is an estimation for benefits.

Initial:

I understand and agree that I will be financially RESPONSIBLE for any and all charges for services not paid by my insurance for my visits. This includes any routine visits and medical services/visits.

Initial:

I understand and agree that I will be financially RESPONSIBLE for any and all charges for materials not paid by my insurance... glasses, contacts, etc.

Initial:

I understand that if I need a copy of my records there will be a $25 charge for any additional copies after my last visit.

Initial:

I understand this office's policy is that they do NOT file for secondary insurance.

Initial:

By signing below I have read and understand my RESPONSIBLITIES and agree to the terms.

Print Name:

Print name of Responsible Party if different from patient

Date:

* Required field