Financial Responsibility Agreement

Financial Responsibility Agreement

I understand and agree that I will be financially responsible for any and all changes for services not paid by my insurance for my visits. This includes any medical service or visit, Preventive exam or physical, lab testing X-rays. EKG and any other screening service or diagnostic testing ordered by the physician or the physicians staff.

I understand and agree it's my responsibility and not the responsibility of the physician or clinic to now if my insurance will pay for my medical service or visit, Preventive exam or physical, lab testing X-rays. EKG and any other screening service or diagnostic testing ordered by the physician or the physicians staff.

I understand and agree it is my responsibility to know if my insurance has any Deductible, Co-payment, Co-insurance, Out-of-network amount, usual and customary limit or any other type of benefit limitation for the service I receive, and I agree to make full payment.

I understand and agree it is my responsibility to know if the physician or provider I'm seeing is a contracted in-network provider recognized by my insurance company or plan. If the physician or provider I'm seeing is not recognized by my insurance company or plan, it may result in claims being denied or higher out of pocket expense to

me. I understand this and agree to be financially responsible and make full payment.

I understand and agree it is my responsibility to know if my PCP choice has been processed by my insurance company or pian. If I have requested a PCP change that is not processed by my insurance company, it may result in claims being denied. I understand this and agree to be financially responsible and make full payment.

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Please do not submit any Protected Health Information (PHI).

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