Horizon

PATIENT INFORMATION FORM
Patient Name: (Last)
(First)
(MI)
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Please present your insurance card to staff at the front desk.

Thank you for selecting Horizon Wellness Services for your healthcare needs. We are honored to be of service to you and your family. This is to inform you of our billing requirements and our financial policy.

[FOR CASH-ONLY PRACTICES] Please be advised that payment for all services will be due at the time services are rendered, unless prior arrangements have been made. For your convenience, we accept [PAYMENTS YOU ACCEPT (E.G., VISA, MASTERCARD, CHECKS,

[FOR PRACTICES ACCEPTING INSURANCE] Please be advised that payment for all services will be due at the time of services rendered, unless prior arrangements have been made. We accept some forms of insurance. Please discuss your insurance coverage with a staff member.

I agree that should this account be referred to an agency or an attorney for collection, I will be responsible for all collection costs, attorney's fees, and court costs.

I have read and understand all of the above and have agreed to these statements.
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PATIENT INFORMATION FORM