(315)426-0190
Fax: 426-0192
Irving
G. Raphael, M.D. Deborah
Pflugh, RNC, ANP
Michael
P. Nancollas, M.D. Nancy
Parsons, RNC, ANP
Wayne
Eckhardt, M.D.
Carri
Jones, M.D. Amy
Gemelli, RPA - C
Renee
Melfi, M.D.
Daniel
C. Wnorowski, M.D. Daniel
DeMartini, RPA - C
Richard
DiStefano, M.D.
PATIENT AGREEMENT
FOR FINANCIAL RESPONSIBILITY
Due to the varied requirements of insurance
companies some services and items may not be covered by your insurance
program. By signing this agreement you
(the patient) acknowledge that you are assuming
ALL financial responsibility for charges associated with your
visits, (including charges for x-ray and durable medical equipment) not covered
by the insurance (s) noted below.
Additionally, if your insurance requires a
specialist referral for your care, you (the patient) are responsible for
verifying that your Primary Care Physician has completed the referral. If the requirements of you insurance plan
have NOT been met, you (the patient) assume ALL financial
responsibility for those charges.
Insurance:
____________________________________________________
Patient Identification #:
_________________________________________
Patient Signature: _________________________________ Date: ________________
(Parent/Guardian
if patient is a child)