Patient Financial Responsibility Agreement PDF Updated July 11 ... 2026

1. Click ‘Get Form’ to open the Patient Financial Responsibility Agreement in the editor.
2. Begin by reviewing the Insurance Claims/Payment section. Initial where indicated to confirm your understanding of your financial responsibilities regarding insurance claims.
3. Proceed to the Cash Services section. Again, initial as required to acknowledge that certain services are not covered by insurance and will require upfront payment.
4. Fill out the Patient Account Charges and Statements section, ensuring you understand payment expectations at the time of service. Initial accordingly.
5. Review and initial the Collections section, which outlines potential fees for overdue accounts.
6. Complete the Returned Checks section by initialing to acknowledge the NSF fee policy.
7. Initial the No Show and Cancellation Charges & Late/Rescheduling Fees section, confirming your understanding of associated fees for missed appointments.
8. If opting for credit card payment authorization, fill in your card details in the designated area and ensure all information is accurate before signing.
9. Finally, sign and date at the bottom of the form to confirm your agreement with all terms outlined in this document.

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