Patient Responsibility Payment Agreement

To better serve our patients, we understand the need for clear communication of our financial policies. Please understand that payment for service is an important part of our professional relationship and we strive to be good stewards of your healthcare expenses. Prior to receiving products we require a form of payment on file to satisfy any balances that are the responsibility of the patient. If you have provided insurance coverage to us, we will bill your insurance company with the necessary information. Our office will send an invoice to you once your patient balance is determined. The credit card or bank account listed below will be charged on the due date specified on your invoice. All payments and refunds to your account will be recorded or made by Tg Oxygen, LLC which is Fairway Medical’s legal name.