Acknowledgement

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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: