Patient Financial Liability and Responsibility Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.The patient (or patient’s guardian, if the patient is a minor) is ultimately responsible for the payment for all treatment and care provided by Building Bridges Through Communication (BBTC). BBTC is pleased to assist patients by submitting claims to contracted insurance carriers. However, it is the patient’s responsibility to provide complete, accurate, and up-to-date insurance information at all times. The patient will be financially responsible for any charges incurred as a result of incorrect, incomplete, or outdated insurance information. Patients are responsible for payment of all applicable copayments, coinsurance, deductibles, and for any services, or treatments that are not covered by their insurance plan. / Guardian Parent Additional Charges Patients may incur, and are responsible for payment of, additional charges at the discretion of BBTC. The charges may include, but are not limited to: Fees for returned or declined checks Fees for missed appointments or cancellations without 24 hours advance notice Any costs associated with the collection of outstanding patient balances Monthly Statements & Payment Processing Beginning on the effective date of this agreement, all clients will receive a monthly client statement outlining the client’s financial responsibility for all activity on the patient’s account from the previous month. Statements will be issued once per month. If payment is not received by another method within three (3) business days of the statement date, the outstanding balance will be automatically processed using the card on file. If you wish to make payment using a different method, you may do so through the patient portal or by contacting the BBTC office within this three (3) business day timeframe. Acknowledgement By signing below, I acknowledge that I have read, understand, and agree to the financial responsibilities and payment policies outlined above. Type Patient / Parent / Guardian Name to Sign *Date Signed"Legal" Consent *I understand that typing my name here constitutes a legal electronic signature.Submit