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To assist in understanding that financial responsibility, we ask that you read and sign this form. Feel free to ask if you have any questions regarding your financial responsibility.

PATIENT RESPONSIBILITY FORM 1. INDIVIDUAL’S FINANIAL RESPONSIILITY I understand that I am financially responsible for my health insurance deductible, coinsurance or non-covered service. Co-payments are due at time of service. If my plan requires a referral, I must obtain it prior to my visit.

Agreement of Financial Responsibility. Thank you for choosing us as your health care provider. We are committed to providing quality care and service to all of our patients. The following is a statement of our financial policy, which we require that …

A patient financial responsibility agreement, also known as a patient financial agreement or a patient financial responsibility form, is a legal document that outlines the financial obligations and responsibilities of a patient for the healthcare services they receive.

Patient Name: (Patient Label) Dear Patient, Due to increasing complexity in the healthcare industry, it is important for us to understand the precise nature of your doctor visit today. Identifying services and properly coding the visit will allow your insurance company to properly allocate financial responsibility. Also, we want you to know

Patients are responsible for the payment of copays, coinsurance, deductibles, and all other procedures or treatment not covered by their insurance plan. Payment is due at the time of service, and for your convenience, we accept cash, check, and …

Patients are responsible for payment of co-pays, co-insurance, deductibles, and all other procedures or treatment not covered by their insurance plan. Copays are due at the time of service. Coinsurance, deductibles, and non-covered …

This form is utilized after the patient has been provided with the notification of financial assistance and charity care program. PATIENT AGREEMENT OF FINANCIAL RESPONSIBILITY . Made accessible 1/23 *

for help applying, or call 800-992-2279 to request an application form. The Medical Financial Assistance program covers medically necessary care provided at a Kaiser Permanente medical facility or pharmacy, or provided by a Kaiser Permanente provider.

As a patient, it is in your best interest to know if your insurance plan covers the provider you are seeing. Understanding your insurance plan and benefits is the patient's responsibility: any deductibles, co-insurance, or co-payment amounts are due at the time of the visit.