Thank you for choosing Mobile IV Medics. The services you seek imply a financial responsibility on your part. This responsibility obligates you to ensure payment in full for the services you receive. To assist in understanding that financial responsibility, we ask that you read and acknowledge this form. Feel free to ask if you have any questions regarding your financial responsibility. If someone else (parent, spouse, domestic partner, etc.) is financially responsible for your expenses, please share this policy with them, as it explains our practices regarding billing. By acknowledging and/or by receiving services from the Medical Provider, you agree: 

1. You will be required to follow all registration procedures, which may include updating or verifying personal information, presenting verification of identity, providing signatures, and paying for all services. You acknowledge and agree to the established policies and procedures of Medical Provider, including but not limited to this PATIENT FINANCIAL RESPONSIBILITY STATEMENT, in effect from time-to-time (“Policies”). These Policies may be changed from time to time by Medical Provider, without notice. If there is any conflict between another policy or procedure of Medical Provider and this PATIENT FINANCIAL RESPONSIBILITY STATEMENT, this Statement shall control. 

2. You are ultimately responsible for all payment obligations arising out of your treatment or care and guarantee payment for these services. You are responsible for knowing your insurance policy. You acknowledge that the Medical Provider does not accept or bill insurance and you will be deemed a self-pay patient. As a self-pay patient, our fee is expected to be paid in full at the time of service. 

3. Payment of any account balance is due at the time of provided services. If any balance on your account is over fifteen (15) days past due, your account will be in default and auto referred to a collection agency. The balance of any account not paid within fifteen (15) days will begin to accrue interest at the maximum rate allowed by applicable law. 

4. We accept payment by cash, debit cards, or credit cards. Your payment with a credit or debit card may be made in person, online, or by calling the Medical Provider. All regular debit or credit card rules will apply. Once authorization on the submitted information is received, your credit card will be charged. If your charge is not accepted, you will be notified. You are responsible for all late charges or penalties resulting from the late receipt of any payment. Your information is used solely to process your payment. You authorize a form of payment such as a credit or debit card to be stored on file. If you are not prepared to make payment for services in full, your visit may be re-scheduled or canceled 

5. Additional Charges. Patients may incur and are responsible for the payment of additional charges at the discretion of the Medical Provider including but not limited to: (i) charges for a missed appointment without 24 hours advance notice; (ii) charges for copying and distribution of records; (iii) charges for extensive forms preparation or 

completion; or (iv) any costs associated with collection of patient balances, all as allowed by law. 

6. Non-payment on Account. Should collection proceedings or other legal action become necessary to collect an overdue or delinquent account, you understand that Medical Provider has the right to disclose to an outside collection agency or attorney all relevant personal and account information necessary to collect payment for services rendered. You are responsible for all costs of collection including, but not limited to: (i) late fees and charges and interest due as a result of such delinquency; (ii) all court costs and fees to the extent allowed by law; and (iii) a collection fee to be charged under separate agreement with a third-party collections agency, either as a flat fee or computed as a percentage of the total balance due up to the maximum allowed by applicable law, and to be added to the outstanding balance due and owing at the time of the referral to the third party collection agency. You acknowledge that any such interest assessed on the account will be a late fee as a result of default or delinquency on your account, and is not deemed interest as part of a credit transaction. If your account is referred to a collection agency, attorney, court, or the past due status is reported to a credit reporting agency, it may have an adverse effect on your credit history; and related portions of your account, including the fact that you received treatment at our offices, may become a matter of public record. Failure to comply with any of these policies may also result in a Credit Withdrawal of Care. By acknowledging, you agree, on behalf of yourself, your legal representatives and next of kin, that the jurisdiction, venue, and choice of law of any dispute or state court action related to the health care services or the billing provided by Medical Provider shall, at the option of Medical Provider, be subject to the exclusive jurisdiction of (i) the appropriate court in the state where the provider of the disputed services is physically located when the services are rendered or (ii) where you reside. 

7. Minor Patients. The parent/guardian of a minor is responsible for payment of the minor’s account balance. A minor who is not accompanied by a parent/guardian will be denied any non-emergency treatment unless charges for the treatment have been pre-authorized. Responsibility for payment of treatment of minor children, whose parents are divorced, rests with both parents. Any court-ordered responsibility judgment must be determined between the individuals involved, without the inclusion of Medical Provider. 

8. Authorization to Contact. You authorize Medical Provider personnel to communicate by mail, voice mail, text message, and/or e-mail according to the information provided in your patient registration information. Medical Provider, or any agent or servicer of your patient account, may use any information you have provided, including contact information, e-mail addresses, cell phone numbers, and landline numbers, to contact you for purposes related to your account, including debt collection. You authorize Medical Provider to use this information in any manner consistent with the information you have provided, including mail, telephone calls, e-mails, or text messages. You expressly consent to any such contact being made by the most efficient technology available, including automatic dialing/e-mailing or similar equipment, or pre-recorded or other messages, even if you are charged for the contact. 

9. Financial Responsibility Party. If this or a separate Medical Provider Financial Responsibility Statement is acknowledged by another person, on your account, then that co- acknowledgment remains in effect until cancelled in writing. Cancellation in writing shall become effective the date after receipt, and shall apply only to those services and charges thereafter incurred. By acknowledging as Financial Responsibility Party, you hereby guarantee the full and prompt payment to Medical Associates of all indebtedness of Patient to Medical Provider, whether now existing or hereafter created (the “Indebtedness”); and you further agree to pay all expenses, legal or otherwise, incurred by Medical Provider in collecting the Indebtedness, in enforcing this guaranty, or in protecting its rights under this guaranty or under any other document evidencing or securing any of the Indebtedness. This guaranty shall be a continuing, absolute and unconditional guaranty, and shall remain in force and effect until any and all said Indebtedness shall be fully paid. There shall be no obligation on the part of Medical Provider at any time to first exhaust its remedies against Patient, any other party, or any other rights before enforcing the obligations of Financial Responsibility Party. 


I acknowledge that: (i) I have been provided a copy of the Medical Provider PATIENT FINANCIAL RESPONSIBILITY STATEMENT; (ii) I have read, understand, and agree to their provisions and agree to the specified terms; (iii) I agree to pay all charges due (or to become due) to Medical Provider for the below Patient’s care and treatment (iv) if I failed to make any of the payment for which I am responsible in a timely manner, I will be responsible for all costs of collecting the money owed, including court costs, collection agency fees, and attorneys’ fees to the extent allowed by law; and (vii) failure to pay when due may subject me to late payment charges and can adversely affect my credit report. I further agree that a copy of this Patient Responsibility Financial Statement shall be as valid as the original.