I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and me. Furthermore, I understand that Dr. Masulas’ Office will prepare any necessary reports and forms to assist me in making collection from my insurance company and that any amount authorized to be paid directly to the Doctor’s Office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate, any fees for professional services rendered me will be immediately due and payable. The patient also agrees that he/she is responsible for all bills incurred at this office. Parental Consent for Minor Patient.
My signature below indicates that I have read, understand and agree to all of the above listed information.