Financial Agreement
The above information is true to the best of my knowledge. I understand and agree that I am ultimately responsible for the balance for myself and all my identified children under 18 years of age as listed above for any professional services rendered. I understand and agree that I am responsible to pay any co-pays at the time of the service. Should my insurance claim be denied for lack of eligibility or termination of coverage, I understand that I will be held responsible and intend to make payment in full to Forme Rehabilitation, Inc. dba Forme Urgent Care and Wellness Center. I acknowledge that I will be billed for my deductible and/or coinsurance by Forme and hereby agree to make such payment upon receipt of bill.
IMPORTANT READ - INSURED PATIENT:
There will be a $25 fee for any missed visits for primary care and $50 fee for Specialties if you do not notify us at least 24 hours prior to your scheduled appointment time.
IMPORTANT READ - SELF PAY PATIENT:
As a self-pay patient, I understand that I will be responsible for payment of all lab work and will be billed separately by Quest Diagnostics.
There will be a $25 fee for any missed visits for primary care and $50 fee for Specialties if you do not notify us at least 24 hours prior to your scheduled appointment time.