Insurance Billing Agreement

Please type your initials after each of following statements below in the box provided on the right to indicate that you have read and understand our billing policies.

Dear Patient;
This letter sets forth our office insurance billing policy:

I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO KNOW WHAT THE TERMS OF MY INSURANCE ARE, AND IN COMPLIANCE WITH THOSE TERMS, AGREE TO THE FOLLOWING:

I HAVE READ AND AGREE TO THE TERMS OUTLINED ABOVE: