Patient:

Date of Birth:

Financial Responsibility Policy:

Payment for services are due each visit for charges incurred up through

your last visit. We accept cash, checks, and Zelle. Please understand that you are financially responsible for all charges.

Please read carefully and initial each statement:

_____ All payments are due on the date of service.

_____ Significant Steps does not accept insurance payments at this time. Payments are due on date of service, but we will provide a superbill for you to submit to insurance upon request.

_____ All invoicing will be sent by email. Please make sure your email address is up to date.

_____ Any returned checks or electronic payment will be charged a fee of $50.

_____ Any bill that is not paid within 90 days will be placed in a collections status and turned over to a collection agency. A 30% service charge will be added to all balances sent to collections.

I hereby understand the above financial policy and agree to abide by it.

_______________________________________        ______________________

Patient/Parent/Legal Guardian Signature                 Date

_______________________________________

Patient/Parent/Legal Guardian Printed Name