An insured patient, or child named on their parents or guardians policy, is liable for the care he or she receives. Should the insurance provider determine that the care and treatment is not covered under the patients policy, the patient, or their parents/guardian agree, that he or she will be liable for the portion of the charges that are not settled.
Self Funding Patients:
In consideration of the services extended, I do hereby accept responsibility for the payment of all charges for such services provided to the patient.
Please let me know if there is anything else you need in the meantime.