LOUDOUN OB/GYN ARSHED CHOUDHRY, M.D., F.A.C.O.G. Y. LISA HYUN-PARK, M.D., F.A.C.O.G. MICHELLE ROBERTS-BORDEN, M.D., F.A.C.O.G. JENNIFER THOMPSON, M.D., F.A.C.O.G. Obstetrics · Gynecology · Infertility Patient Responsibility Form Your signature below forms a binding agreement between Loudoun OB/GYN and the patient who is receiving medical services, or the Responsible Party for minor patients (patients under 18 years old). Responsible party is the individual who is financially responsible for the payment of medical bills. We participate with many insurance plans and bill them as a service to you. Ultimately, you are responsible for charges not covered by your plan. If you are not sure about our provider status with your plan, please contact your insurance company or our billing office at 703-443-6717. Patient Financial Responsibilities: • The patient or responsible party is ultimately responsible for payment for treatment and care • We will bill your insurance; however, patients are required to provide the most current insurance information at each visit • Patients are responsible for payment of copays, coinsurance, deductibles and all other services provided that are not covered by their insurance plans • Copays are due at time of service • Coinsurance, deductibles and non-covered items are due 30 days from receipt of billing • If you do not have insurance, payment is due at time of service in full. • If you are a no show for your appointment, you will be charged a $50 fee. Cancellations must be 24 hours in advanced. By signing below, you agree to accept full financial responsibility as a patient who is receiving medical services, or as the responsible party for minor patients. Your signature verifies that you have read the above disclosure statement, understand your responsibilities, and agree to these terms. ________________________________________________ ____________________ Patient Name (Please Print) Patient Date of Birth ________________________________________________ ____________________ Patient Signature Date
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LOUDOUN OB/GYN ARSHED CHOUDHRY, M.D., F.A.C.O.G. Y. LISA HYUN-PARK, M.D., F.A.C.O.G.
MICHELLE ROBERTS-BORDEN, M.D., F.A.C.O.G. JENNIFER THOMPSON, M.D., F.A.C.O.G.
Obstetrics · Gynecology · Infertility
Patient Responsibility Form
Your signature below forms a binding agreement between Loudoun OB/GYN and the patient who is receiving medical services, or the Responsible Party for minor patients (patients under 18 years old). Responsible party is the individual who is financially responsible for the payment of medical bills. We participate with many insurance plans and bill them as a service to you. Ultimately, you are responsible for charges not covered by your plan. If you are not sure about our provider status with your plan, please contact your insurance company or our billing office at 703-443-6717. Patient Financial Responsibilities:
• The patient or responsible party is ultimately responsible for payment for treatment and care
• We will bill your insurance; however, patients are required to provide the most current insurance information at each visit
• Patients are responsible for payment of copays, coinsurance, deductibles and all other services provided that are not covered by their insurance plans
• Copays are due at time of service • Coinsurance, deductibles and non-covered items are due 30 days from receipt of billing • If you do not have insurance, payment is due at time of service in full. • If you are a no show for your appointment, you will be charged a $50 fee. Cancellations
must be 24 hours in advanced. By signing below, you agree to accept full financial responsibility as a patient who is receiving medical services, or as the responsible party for minor patients. Your signature verifies that you have read the above disclosure statement, understand your responsibilities, and agree to these terms. ________________________________________________ ____________________ Patient Name (Please Print) Patient Date of Birth ________________________________________________ ____________________ Patient Signature Date
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