Patient Responsibility Agreement

This is to inform you that your insurance carrier may cover procedures or diagnostic tests that your doctor consider necessary for the proper treatment of your medical condition. We agree to file the claims for you and assist in any appeal process necessary.

You understand that your Provider and/ or you may appeal any determination that a Benefit Agreement of Evidence of Coverage. You may have the right to Independent Medical Review through DMHC.

Your signature on this form acknowledges that you agree to bear full financial responsibility for all service provided if:

  1. The Services are not covered by your insurance carrier, or
  2. The Services have not been otherwise approved for payment.

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.