New Patient Non-Payment

 

                                                JUDY J. DAVIS M.D.,F.A.A.P.

                                                  FRESNO ENDOSCOPY CENTER




***In the case of Non-Payment by Insurance***



We are glad that you have chosen our office. We, as a courtesy to you, will gladly

bill your insurance. However, in the event that payment for your treatment is

denied by your insurance company, we would like you to know that it is ultimately

the patient’s responsibility, if you accept treatment with or without pre-

authorization.


Thank you again for choosing our office.

We are glad to be of service to you.



_______________________________                      ______________________________

Print Patient’s Name                                                  Patient/Guardian signature





***En el caso de que su azeguranza no cobra***



Gracias por escojer nuestra oficina. Como cortesia de nuestra parte nosotros

cobramos a su azeguranza. En el evento de que su azeguranza no cobra por su

tratamiento, usted, el paciente, es responsible por su tratamiento.


Gracia por escojer nuestra oficina.



_______________________________                       _____________________________

Nombre de paciente                                                   Firma de paciente/guardian                 

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