Financial Responsibility

Please correct the errors described below.

Financial Responsibility

I authorize payment of medical benefits directly to Koger Dermatology, PC for any services rendered by Dr. O'Neal Koger, Jr. or Dr. Rhodonna Anderson. I understand that I am responsible for any amounts not covered by my insurance, including reasonable attorney's fees and cost of collections in the event of default. Date I further understand that if payment becomes 30 days past due, a $30 finance charge will be added to my bill. Lastly, I understand that there will a $25 ($50 for Saturday) NO SHOW FEE assessed for any appointments not cancelled within 24hrs of the scheduled appointment time.

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.

Acknowledgement of Receipt of Notice of Privacy Practices:

I acknowledge that I was provided a copy of the Notice of Privacy Practices. I have ready or had the opportunity to read (If I so choose) and understand the notice.

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.

Insurance Authorization

I authorize the release of my medical/ medication history information (if necessary) to process this or any future claims for services provided by Dr. O'Neal Koger, Jr. or Dr. Rhodonna Anderson. This authorization is valid until revoked in writing.

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.

Your information will be encrypted.

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