FINANCIAL RESPONSIBILITY and CONTACT INFORMATION AUTHORIZATION
As a courtesy, our practice will file your claim electronically with your insurance company. You will be billed for charges not covered by your insurance company and payment is expected within thirty (30) days of receipt of our billing statement. Delinquent accounts may be placed with a collection agency. In the event that your unpaid balance is turned over to a collection agency for recovery, collection and attorney fees will be added to your balance. Returned checks will incur a $30.00 service fee.
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