My signature below certifies that I have read and agree to Healthcare Provider’s payment policy. I am eligible for the insurance indicated on this form, and I understand that payment is my responsibility regardless of insurance coverage. I authorize Healthcare Provider to release any medical information to my insurance carrier or third-party payer to facilitate the processing of my claims. I choose to receive communications about appointments, feedback, treatment, and payment from Healthcare Provider at the number or address above.
Note: You need to sign this to submit this form. Simply type a name.
Please enter your email address below to receive an automated message similar to what we send to our healthcare provider clients, including a PDF of the completed form with all of the form data above filled out. Note: This will NOT trigger any automated marketing.
