By agreeing to this form you agree that the information provided during the registration process is true to the best of your knowledge. You authorize your insurance benefits to be paid directly to the provider. You understand that you may be financially responsible for any balance not covered by your insurance benefits. You also authorize your insurance company to release any information required to process my claims.
Patient Billing Responsibility
Patient billing is the responsibility of the patient and the case when your insurance does not cover the full build or the allowable amount of your office visit. A statement will be generated and sent to you with any outstanding balances. By agreeing you understand and agree to this responsibility.
Missed Appointments Agreement
Given the nature and mobility of our practice canceled appointments must be greater than 24 hours prior to your scheduled time. Failure to do so will result in a $120 missed appointment charge. Agreeing to this form acts as your full understanding of this and obligation to pay should you cancel during the 24 hour window of your scheduled appointment.
Patient Attestation Agreement
I have read the above Patient Attestation Form
I confirm that signing below will be an official signature.