Patient Information Form

Please correct the errors described below.

I understand that regardless of insurance liability, I am responsible for payment of any charges incurred in this medical practice. If this account becomes delinquent and is placed for collection, I agree to pay all charges related to said collection activity including but not limited to collection agency fees, court costs and sheriff service fees.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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