Style 6 Demo

Financial Responsibility

Our payment policy and your acknowledgment.

Financial policy

Payment is due when you receive care unless we have agreed a payment arrangement in advance.

If you have insurance, we will bill your plan for you. Any estimate we give is based on the information available to us and is not a guarantee of what your plan will pay. You are responsible for any amount your plan does not pay, including deductibles, co-payments and services it does not cover.

If you need to cancel or reschedule, please tell us as early as you can, and ask our staff about our cancellation policy.

Questions about a bill? Contact Style 6 Demo and we'll explain it.

Patient Name *

Email *

Your coverage for care with us *

I have insurance and want it billed

I don't have insurance

I have insurance but will pay myself

Because you are uninsured or paying for yourself, you have the right to a Good Faith Estimate of the expected charges for your care. When you schedule care at least 3 business days ahead, we will give you one in writing before your visit, and you can ask us for one at any time.

Preferred Payment Method

Who is signing this form? *

Patient (myself)

Parent or legal guardian

Other legal representative

Your full name *

Your authority to sign for the patient (for example, parent, court-appointed guardian or health care power of attorney) *

I have read this financial policy and I agree to it. *

By signing below, you confirm the information you gave is accurate to the best of your knowledge and you agree to sign this form electronically. Your electronic signature has the same effect as a handwritten one. You can ask Style 6 Demo for a paper copy of this form at any time.

Date *

Signature *

Your information is encrypted and transmitted securely under HIPAA.

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