· all insurance benefits, if any, otherwise payable to me for services rendered I understand that...

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Transcript of  · all insurance benefits, if any, otherwise payable to me for services rendered I understand that...

Page 1:  · all insurance benefits, if any, otherwise payable to me for services rendered I understand that I am financially responsible for all charges whether or not paid by insurance.
Page 2:  · all insurance benefits, if any, otherwise payable to me for services rendered I understand that I am financially responsible for all charges whether or not paid by insurance.
Page 3:  · all insurance benefits, if any, otherwise payable to me for services rendered I understand that I am financially responsible for all charges whether or not paid by insurance.
Page 4:  · all insurance benefits, if any, otherwise payable to me for services rendered I understand that I am financially responsible for all charges whether or not paid by insurance.
Page 5:  · all insurance benefits, if any, otherwise payable to me for services rendered I understand that I am financially responsible for all charges whether or not paid by insurance.
Page 6:  · all insurance benefits, if any, otherwise payable to me for services rendered I understand that I am financially responsible for all charges whether or not paid by insurance.
Page 7:  · all insurance benefits, if any, otherwise payable to me for services rendered I understand that I am financially responsible for all charges whether or not paid by insurance.