Patient Financial Responsibility

Please read and sign where indicated.  This document describes your financial responsibilities.

__I agree to be financially responsible for payment of Fairlawn Family Practice services.  Check, credit cards, MasterCard, Discover and Visa are acceptable forms of payment for these services.  We accept no cash.

__Current insurance cards must be presented at every office visit.  I agree to pay the remaining balance after my insurance has paid on my claim immediately upon receipt of a statement.

__I understand if my account becomes over 30 days past due there may be a Statement Fee added each month of $10.00 to cover the costs of billing.

__I agree to give Fairlawn Family Practice my complete and accurate insurance information for primary and secondary insurance benefits.  I understand that if I fail to give complete and accurate information about my insurance benefits this may result in a denial of my claim or a delay in payment at which time balance is due in full.

__I understand there will be a $35.00 fee for all returned checks.

__If I have a high deductible policy or do not currently have insurance benefits, I agree to pay an estimate of charges for my office visit in advance and understand that other charges may apply.

__Fairlawn Family Practice may or may not have a contract with your insurance company.  Fairlawn Family Practice will receive payments from my insurance company for covered services provided by my insurance benefits.  I agree to pay co-payments and deductible at the time of service.  If co-payments are not made at the time of service, I understand that my appointment may be rescheduled.

__I agree to pay any balance remaining on my account for any reason upon receipt of a statement and I understand that when requested, I must give Fairlawn Family Practice my current address and other contact information.  I understand that if I fail to pay the balance on my account this may result in Fairlawn Family Practice pursuing any collection means possible along with discharge from the practice.

__If my account becomes delinquent, it may be forwarded to an outside collection agency without notice.  If this happens, I will be responsible for all costs of collection, including but not limited to interest, rebilling fees and collection agency costs.

__If the reason for my appointment is related to a work injury, I agree to give Fairlawn Family Practice the claim number, the workman’s compensation or insurance carrier name, address or other contact information at the time of my appointment.  If I do not provide this information at the time of the visit, I agree to pay all charges for my visit.

I have read and I understand Fairlawn Family Practice’s financial policies and I accept responsibility for the payment of any fees associated with my care.


Patient Signature                                                                                       




I hereby authorize direct payment of medical benefits, including medical benefits to which I am entitled to Fairlawn Family Practice.  This is a DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS.  This authorization will remain in effect until cancelled by me in writing.  A copy of this authorization is as valid as the original document.

I authorize the release of any medical information necessary in order to obtain payment and I understand that I am financially responsible for all charges, late fees and collection charges considered patient responsibility by my insurance company.  I understand that if I am not insured I am responsible for the charges of all services provided to me. 



Patient Signature