Insurance Agreement

Please correct the errors described below.

An agreement to personally pay should medicaid or private insurance deny payment

We will attempt to collect for medical services rendered by our office by billing your insurance company. However, if your insurance company does not pay claim for services rendered by our office, you will be billed directly.

By signing this form, you are agreeing to pay for any services rendered to you by our office provided that your insurance plan defines as non-covered services or due to ineligibility.

Your information will be encrypted.