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Financial Agreement

Financial Agreement

  • In order to control the cost of billing, we ask that the patient’s portion is paid at the time services are rendered unless other arrangements are made in advance. All professional services and materials are charged to the patient. The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance, any account 90 days past due are subject to collections fees. There will be a service charge on all returned checks.

    Payment from my insurance company is to be paid directly to Dr. Kristin Campbell and/or Dr. Carrie McMahon. I understand that all benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made when the claim is processed.
  • Date Format: MM slash DD slash YYYY