Insurance companies will only release a quote for benefits regarding your insurance coverage. This quote is not a guarantee of coverage or payment. Please be advised that it is your responsibility to ensure payment for services. If your insurance company does not pay, you will be responsible for the charges. For this reason, Capital Family Practice requires patients receiving ancillary services to sign the financial responsibility agreement below. Please print, read, and sign this form prior to your appointment. You must provide this completed form to the front desk before services can be rendered. Thank you for your understanding and cooperation.
I understand the services listed below may be non-covered services under my insurance plan. Should my insurance deny payment for any of these services, I agree to be fully responsible for the timely payment of these charges in full. My signature below authorizes my medical care provider to render these services to me.
