Financial Acknowledgement

 Acknowledgement Letter

 

I acknowledge that all services must be paid for at the time of service. I also acknowledge that some services (C-Sections, Emergencies, etc.) must be pre-paid for, due to the nature of the services. If for any reason the total amount for services exceeds the estimated amount pre-paid, I agree to pay the remaining balance due. I understand that an estimate is that, an estimate, and that the services and charges may exceed the estimate given, as the case arises.

If payment in full is not received at the time of service, I understand and agree that I am liable and agree to pay all responsible attorney fees and or collection agency fees needed to affect collection of any delinquent charges that may be outstanding on my account.

 

____________________________
Printed Name

 

____________________________

Signature

 

________________

Date

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