Scioto urgent form 2025

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The document outlines the privacy and financial policies of Scioto Urgent Care, emphasizing the importance of patient understanding regarding payment responsibilities. It details payment procedures for insured and self-pay patients, including required fees at the time of service and information about accepted insurance providers. Patients are informed that they are ultimately responsible for any costs not covered by their insurance.

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Click ‘Get Form’ to open the scioto urgent form in the editor.
Begin by entering your personal information in the designated fields, including your name and contact details. Ensure accuracy for seamless processing.
Review the payment policy section carefully. If you have insurance, provide your current insurance card details and any copay amount required at the time of service.
For self-pay patients, indicate your understanding of the $135.00 fee for a basic office visit and any additional fees for procedures like x-rays or lab work.
In the acknowledgment section, fill in your name where indicated and sign to confirm that you understand your financial responsibilities.
Finally, date the form appropriately before submitting it through our platform for processing.

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