I have read and understand the above codes and fees and I understand the cost of my care with my treating doctor. I understand that I am responsible for payment of all deductibles and copayments related to my care. I also understand that if I have a balance for medical services not paid, I will make a minimum payment of 20% (auto debit) of the outstanding balance or $50, whichever is greater, each month. If my balance is not paid in a timely and monthly fashion, I promise to pay any and all collection, court and attorney’s fees accumulated in the collection of my outstanding balance. I further understand that if my treatment is associated with a personal injury claim, all medical bills will be paid at 100% of the above fee schedule regardless of the outcome of my case. I understand that if a check or debit is returned for insufficient funds, I will be charged a $35 service fee.
I further understand that if any of my insurance companies declined payment, I authorize Dr. Perkins to file small claims on my behalf against my insurance company as a method of collection. I also understand and agree that I will be present at the court date if needed. I have read and fully understand the above financial terms and prices. By my mark below I consent to the above financial terms and prices.
