Acknowledgement
By signing below, each of the undersigned acknowledges that: (a) I have been provided a copy
of
the Sun Radiology patient financial responsibility statement ; (b) I have
read, understand, and agree to their provisions and agree to the specified terms; (c) I
agree to
pay all charges due (or to become due) to Sun Radiology for the below Patient’s care and
treatment, including co-payments and deductibles, as required or provided pursuant to my
insurance plan and/or the insurance plan of another, as applicable; (d) benefits, if any,
paid
by a third-party will be credited on the Patient account; (e) regardless of my insurance
status
or absence of insurance coverage, I am ultimately responsible for the balance on the account
for
any services rendered; (f) if I failed to make any of the payment for which I am responsible
in
a timely manner, I will be responsible for all costs of collecting the money owed, including
collection agency fees, and (g) failure to pay when due may subject me to late payment
charges
and can adversely affect my credit report.
I further agree that a photocopy of this Patient Responsibility Financial Statement shall be
as
valid as the original.
ONCE I HAVE SIGNED THIS AGREEMENT, WHETHER BY ORIGINAL, FACSIMILE, OR ELECTRONIC (“PDF”) SIGNATURE, I AGREE TO ALL OF THE TERMS AND CONDITIONS CONTAINED HEREIN AND THE AGREEMENT SHALL BE IN FULL FORCE AND EFFECT.
This agreement is effective for one year from the date signed.
Patient Signature: