• Direct Billing to Insurance Agreement

  • The clinic will accept to receive payments directly from my insurance company with the following provisions:
    • I will pay any amount not covered by my insurance company at the time the services are provided.
    • If my insurance company fails to settle any submitted claim within 20 days from the date of claim submission, I will be responsible to pay the full amount and have my insurance reimburse me instead. Any unpaid balance over 30 days from the day of treatment will be subject to interest accumulation of two (2%) percent per month.
  • Date Format: DD slash MM slash YYYY
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