Fillable FINANCIAL AGREEMENT _ Medical Record I/We patient whose (Academic medical center at State University of New York at Stony Brook)

Fill Online, Printable, Fillable, Blank FINANCIAL AGREEMENT _ Medical Record I/We patient whose (Academic medical center at State University of New York at Stony Brook) Form

Use Fill to complete blank online ACADEMIC MEDICAL CENTER AT STATE UNIVERSITY OF NEW YORK AT STONY BROOK pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

FINANCIAL AGREEMENT _ Medical Record I/We patient whose (Academic medical center at State University of New York at Stony Brook)

On average this form takes 4 minutes to complete

The FINANCIAL AGREEMENT _ Medical Record I/We patient whose (Academic medical center at State University of New York at Stony Brook) form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 15 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Academic medical center at State University of New York at Stony Brook

BROWSE ACADEMIC MEDICAL CENTER AT STATE UNIVERSITY OF NEW YORK AT STONY BROOK FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Date:
_
Medical
Record
#:
File#:
_
FINANCIAL AGREEMENT
I/We
hereby agree as follows:
1. Guarantee of Payment. Medical care has been or will be provided to the
patient whose name appears below. I/We, both jointly and individually, shall
be fully responsible for payment of the patient's bill, based on the charges
incurred which
I/We
now
agree are fair and reasonable. The University
Faculty Practice Corporations may demand full payment of the patient's bill at any
time, but the University Faculty Practice Corporations are not required to do this.
Even if the University Faculty Practice Corporations do not demand immediate
payment, my/our obligation to make such payment remains the same.
2. When the Patient's Insurance Coverage is Insufficient. If any insurance
coverage which the patient may have, such as Blue Shield, Medicare,
Medicaid, Compensation or other coverage, rejects the patient's claim or
allows only part of the claim,
I/we
shall be responsible for immediate payment
of the balance due to the extent permitted by law.
3. The Agreement. I/We have read and understood this Agreement and have
received a copy as well.
Name of Patient
Name of Person Guaranteeing
Payment
UNIVERSITY FACULTY
PRACTICE
CORPORATIONS
Signature of Person Guaranteeing
Payment
Home Address
Telephone Number
Employer's Name
Witness PA-29g/7-92 8/2009
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

FINANCIAL AGREEMENT _ Medical Record IWe patient whose (Academic medical center at State University of New York at Stony Brook)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 27 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document