Patient Financial Responsibility

Patient Financial Responsibility
Patient Name

First NameLast Name
DOB

MonthDayYear
Date
Date of Service

MonthDayYear
Date
At the time of your visit today, an estimated copay of copay amount* has been determined based on the information provided by your specific insurance plan with insurance carrier*. This amount is calculated according to your individual benefits and coverage.
**Please be advised that this copay is an estimate only and is not set, controlled, or determined by Parker County Imaging. The final amount owed may change based on the processing of your claim by your insurance company.
Patient Signature

Clear
Parent or Guardian signature if patient is a minor.
Should be Empty: