understand that as a member of my insurance plan, I may be billed for any co-payment, deductibles, non-covered services or any patient balance that I may incur due to services rendered by the office of Anne Thai at 1720 El Camino Real suite 135 or suite 100 in Burlingame CA 94010.
Please refer to your insurance card for applicable information.
In the event that my account is sent to collections all collections fees and or collection cost associated with settling the balance shall be added to my account.
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