Financial Responsibility for Payment

(if other than patient)

 

Name:                                                                           DOB: ____/____/_ _____      Gender:  M    F   Other    

 Social Security No: ____-____-_____       Driver’s License: ____________________________________________  

 Home Address:_______________________________________City________________________Zip___________

 Home Phone: (         ) ______________Cell Phone: (        )_________________Email:______________________

 Employer: ______________________________________________Work Phone: (         )____________________

 Work Address:_______________________________________City________________________Zip___________

 Significant Other(s)/Spouse/Partner (if also claiming financial responsibility):

                                                                 Relationship                         Social

Name: ____________________________  to you: ______________ Security No: ____-____-______

 DOB: ____/____/_ _____      Gender:  M    F   Other;     Driver’s License: ________________________________ 

Home Address:_______________________________________City________________________Zip___________

Home Phone: (         ) ______________Cell Phone: (        )_________________Email:_______________________

 Employer: ______________________________________________Work Phone: (         )____________________

 Work Address:_______________________________________City________________________Zip___________

  I_____________________________________________ hereby assume ALL financial responsibility for

Treatment for _____________________________________ on this  _____ Day of July, 2014.

 ________________________________________________Relationship to Patient_________________

Print Name

 _____________________________________________________

Signature

  I_____________________________________________ hereby assume ALL financial responsibility for

 Treatment for ___________________________________ on this  _____ Day of _______, 2015.

 ________________________________________________Relationship to Patient_________________

Print Name

 _____________________________________________________

Signature