I agree to pay for services rendered. If applicable, I agree to pay for my co-payment or coinsurance at the time of service and I understand that I will be fully responsible for any services deemed as non-covered or denied by insurance company. I also understand that there may be a patient responsibility balance even after my Insurance company has made a payment.

I agree to comply quickly with any request by my insurance company and/or Grapevine Rheumatology Clinic LLC. to assist in quick and efficient payment of my medical claim.

I accept that it is my responsibility to understand and verify that the physicians of Grapevine Rheumatology Clinic are in-network with my insurance plan including any facilities that I may be referred to for further treatment.

If my insurance company requires a referral or prior authorization to see a specialist, I agree to be ultimately responsible in obtaining my referral from my Primary Care Physician (PCP).

Payment can be made in the form of Cash, OR Credit card. In case if check is accepted there will be a $25 per check charge for all returned checks as having non-sufficient funds.

I agree to pay any necessary collection fees if my account becomes delinquent and turned over to a collection agency.

I understand there will be a NO SHOW fee of $50.00 for the first missed appointment and susequently $125.00 for any further missed appointment for any reason I miss my scheduled appointmet with out giving a 48 hours prior notice by personally calling the office. I may not be scheduled for the next follow up unless the amount is paid in full and may be subject to removal from the practice if non complaince to the terms of No Show fee.

I certify that I am 18 years of age and/or the legal guardian/guarantor. I understand and accept full financial responsibility for the patient listed below. Further, I assign insurance benefits for all services rendered by Grapevine Rheumatology Clinic or any other licensed healthcare service provider employed by the company. Additionally, I agree to release all such medical information as may be necessary to assist in payment of medical claims.