PATIENT RESPONSIBILITY FORM
Thank you for choosing Grand Vein Specialists, Ever Clinic as your healthcare provider. We are honored by your choice and are committed to providing you with the highest quality healthcare. We ask that you read this form to acknowledge your understanding of our patient financial policies.
Patients Financial Responsibilities
The patient (or patient’s guardian, if a minor) is ultimately responsible for the payment for her/his treatment and care.
➔ We are pleased to assist you by billing for our insurers. However, the patient is required to provide us with the most correct and updated information about their insurance, and will be responsible for any charges incurred if the information provided is not correct or updated.
➔ 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.
➔ Patients may incur and are responsible for the payment of additional charges at the discretion of Grand Vein Specialists Ever Clinic. These charges may include but are not limited to: