Practice Management Alert

Date:
Patient Name:
Account #:
Outstanding Balance: (Name of Your Business) agrees to hold the outstanding balance of ($0000.00) for up to one year while it is in litigation. If after one year, from the above date, my outstanding balance is still in litigation, my account will be reviewed by (Name of Your Business). If there is a settlement before the one-year date, my outstanding balance of ($0000.00) will be paid in full. If there is not enough in the settlement, I understand that the outstanding balance with (Name of Your Business) is my responsibility. The Patient, (patient or guardian), agrees to be and is fully responsible for total payment of services performed by (Name of Your Business) including any amounts not covered by any insurance or prepayment program the responsible party may have. Signature of Patient (parent or guardian, if patient is a minor) Date, Driver's License Number (*attach copy of driver's license) Signature of Representative of (Name of Your Business) Prevention form contributed by Peggy Schaetz, at Green Bay Plastic Surgical Associates.