Pat ient Name DOB:
Social Security #
Social Security #
Responsible Party Name:
Thank you for choosing us as your healthcare provider. The following is our Financial Policy. If you have any
quesons or concerns about our payment policies, please do not hesitate to ask.
Guarantee of Payment: I hereby acknowledge I am responsible for the payment of all charges for services
rendered to me or the paent indicated above, which I am the responsible party.
1. I understand that all deducbles, co-pays and applicable charges are due at the me of service.
I understand all delivery/surgical fees must be paid in advance of the delivery/surgical date.
2. I understand this office filing a claim with my insurance company or other third-party payer, is a
courtesy only. Under no circumstance, does the filing of a claim relieve me from my responsibility for
the payment of all charges for services rendered.
3. I understand lab services are provided as a courtesy and all lab charges, including genec tesng, are
my responsibility to pay.
4. By signing this document, I personally guarantee the payment of these charges for medical services
rendered. I agree that this authorizaon shall be valid for all Dates of Service. We do NOT file claims
for Workman's Compensaon or claims due to personal injury accidents/illnesses.
5. I understand it is my responsibility to nofy Desert Perinatal Associates, if my insurance benefits or
insurance company changes.
6. I understand it is my responsibility to cancel my appointments at least 24 hours in advance otherwise,
I will be charged a $25.00 non-cancellaon/no show fee.
• Date of Service: the date any medical service is provided.
• Account Balance: the total amount due.
Southwest Location: 5761 S. Ft. Apache • Las Vegas, Nevada 89148
Summerlin Location: 10105 Banburry Cross, #430 • Las Vegas, Nevada 89144
Green Valley Location: 3001 Horizon Ridge Parkway • Henderson, Nevada 89052
Phone: (702) 341-6610 • Fax: (702) 341-6961 •
Definion of Terms:
2 of 2
Collecon of Delinquent Account Terms: Failure to pay my balance within 30 days from any Date of Service is
considered a delinquent account and may result in fees and interest being added to my Account Balance
as follows:
1. Delinquent accounts 30 days past due will accrue interest at a rate of 24% per annum, unl paid in full.
2. An account delinquent with any outstanding balances for 60 days may be forwarded and assigned to a
collecon agency at the paents expense.
3. Any delinquent account assigned to any collecon agency will be charged a collecon fee, which upon
assignment becomes the due and owing Account Balance. COLLECTION FEES ARE BETWEEN 40% and
4. If legal acon is required to collect this account, in addion to any Account Balance, I/We or the
Paents representave who signs below agrees to pay interest as set forth herein, plus all costs
associated with such collecon acvity, including but not limited to all collecon agency fees as set
forth herein as part of the Account Balance, plus any and all aorney fees, court fees, skip tracing fees
and costs in addion to any miscellaneous fees the court of jurisdicon may award.
Collecon Excepons and Exempons: allowed charges under Medicare Title XIX (Nevada
Medicaid) contracts.
Returned Checks or Disputed Credit Card Payment: There is a fee of $35.00 for any returned check for
insufficient funds. If a credit card payment is disputed and payment is wrongfully taken back from Desert
Perinatal Associates by your credit card company, a $40.00 fee will be add to your account. These amounts
may change at any me.
Assignment: If this account becomes delinquent, I/We hereby authorize this office to assign this account
and/or release any necessary informaon to any third party collecon agency. Addionally, if my account is
assigned to any collecon agency, I/We hereby authorize the collecon agency the right to report this account
as delinquent to all the Credit Bureaus.
Signature of Understanding: I have read and understand the financial policy. By signing this form, I consent to
the above terms and condions of treatment and understand that it is my responsibility for assuring that the
financial obligaon of my care is fulfilled. I hereby accept financial responsibility for all charges incurred
whether or not I have insurance coverage.
Signature of Paent or Parent/Guardian if Paent is under 18 year of age
Signature and name of second responsible party for paent listed herein
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