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 •
Paent Name:__________________________________________ Account #:___________________________
As a courtesy, we verify your insurance plan benefits before your appointment(s). Based on the informaon we
receive from your insurance company, we calculate the approximate amount of your co-pay(s), deducble(s)
and/or co-insurance(s) due for the services rendered.
At mes, your insurance company will provide us with different benefits informaon than they have provided
to you. In these instances, we will make every effort to work with you and your insurance company to
determine the correct balance(s) due for the date(s) of service in queson.
I understand and agree to the following regarding my insurance plan benefits:
I agree to pay the full amount(s) due based on the informaon I received from my
insurance company.
I understand that as a courtesy Desert Perinatal Associates will bill my insurance company for
the date(s) of service in queson.
I understand that it is my responsibility to pay any and all balances not paid by my
insurance company.
I have previously read and signed a Financial Policy with Desert Perinatal Associates. An addional
copy will be provided upon request.
Paent Signature:____________________________________________ Date:_________________________
DPA Signature:_______________________________________________ Date:_________________________
click to sign
click to edit
click to sign
click to edit