PATIENT WAIVER FOR NO INSURANCE
*
I acknowledge that I have NO INSURANCE and will be assuming full financial responsibility for today’s visit. If I receive any additional services from specialists, hospitals, laboratories, or other health care providers in connection with or as a result of this visit, those charges will also be my responsibility. Payment must be made today, the date of service, for the entire balance owed to Affiliated Troy Dermatologists. Any additional laboratory, hospital, etc charges will be billed to me.
I acknowledge that I have not provided my correct insurance information to Affiliated Troy Dermatologists and I will be assuming full financial responsibility for today’s visit until I provide the necessary information. If I receive any additional services from specialists, hospitals, laboratories, or other health care providers in connection with or as a result of this visit, those charges will also be my responsibility.
I acknowledge that Affiliated Troy Dermatologists does not accept my insurance and I will be assuming full financial responsibility for today’s visit. If I receive any additional services from specialists, hospitals, laboratories, or other health care providers in connection with or as a result of this visit, those charges will also be my responsibility.
Patient Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Signature of Patient/Guardian
*
Clear
Submit
Should be Empty: