I have elected to have explant specimens collected and sent out, or if Dr. Rankin or his associates deems it necessary that the collected specimens be sent out for further evaluation, I accept full financial responsibility. I understand that Quest Diagnostics will bill my insurance. However, I am required to provide the most correct and updated information regarding insurance.
I understand should I not have insurance coverage that I am responsible for paying in full or paying accordingly to the bill I will receive in the mail from Quest Diagnostics.
I know and understand that I am fully responsible for all charges resulting from services rendered to me and any or all balances remaining after insurance benefits.
I have read, understand, and agree to the provisions of the Patient Financial Responsibility Form.
Please allow the nurse to make a copy of your card.