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Step 1 of 7
Thank you for choosing us as your healthcare provider. We are committed to providing you with the highest quality of care. The following is a statement of our financial policy, which we require you read and agree to sign prior to any treatment.
Patient Financial Responsibilities
Patient or Guarantor
I have read and understand the above. I understand I will be responsible for payment of any amounts not covered by my insurance carrier, including, but not limited to, co-payments and deductibles.