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
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,
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
Signature of Person Guaranteeing
Witness PA-29g/7-92 8/2009