• Guarantor Info (Party Responsible for Payment of Personal Balance

  • Assignment of Benefits: I hereby assign all medical and/or surgical benefits to which I am entitled including major medical, Medicare, private insurance and any other health plans to FAMILY MEDICAL CARE PLUS INC. This agreement will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I also understand that if billing efforts are exhausted in attempting to collect any balance, a 25% collection charge will be assessed to each outstanding claim balance prior to the account being sent to FIRST FEDERAL CREDIT CONTROL for outside collection action.

    Appointment Cancellation and No Show Policy: I understand that if I cancel an appointment less than 24 hours in advance or fail to show up for an appointment I may be charged $25.00 for the missed appointment.

    There will be a $5.00 Processing Fee assessed to your co-pay if you do not pay the time of service.

    PAYMENT / CO-PAY IS EXPECTED AT THE TIME SERVICES ARE RENDERED

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  • By signing below I am verifying that all information above is current on this date.

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