| Today’s Date | _________________________________ |
| Patient’s Name | _________________________________ |
| Guarantor’s Name | _________________________________ |
| Guarantor’s Address | _________________________________ |
| Guarantor’s City, State, & Zip | _________________________________ |
| Printed Provider Name | _________________________________ |
| Procedure or Diagnosis Description | _________________________________ |
| Payment Method (circle one) | Cash - Check - Visa - Master Card - Other __________ |
| Payment Basis (circle one or more) | Total Amount - Co-pay - Deductible - Other __________ |
| Provider Fee (circle one & fill in blanks) |
Exact Amount $ __________________________ | ||
| Published MyHealthScore.com Rate (attached) Plus | ________% | ||
| Published MyHealthScore.com Rate (attached) Minus | ________% | ||
| Medical | $ ___________ | ||
| Surgical | $ ___________ | ||
| Intensive Care | $ ___________ | ||
| Coronary Care | $ ___________ | ||
| ______________ | $ ___________ | ||
| ______________ | $ ___________ | ||
Provider agrees to accept payment as described above as payment in full for treatment of the specified procedure or diagnosis. It is mutually understood that the rate identified above is reduced from the Provider’s Usual and Customary Rates, and will only apply if full payment is received prior to the Patient leaving the Provider’s premises. In the event the payment is not made as stated above, the Guarantor agrees to pay the Provider’s Usual and Customary rate.
Guarantor and Provider understand and further agree: (i) this Agreement is not binding until fully signed by Provider and Guarantor; (ii) the validity and enforceability of this Agreement when signed is subject to applicable laws; (iii) Provider may require Patient/Guarantor to complete and sign other forms and agreements before agreeing to render treatment (e.g., patient history, treatment consent, release of information, etc...); (iv) MyHealthScore.com is not responsible for the participation, or withdrawal from participation, herein by any Provider. Provider and Patient /Guarantor hereby release and agree to hold harmless MyHealthScore.com and its affiliates and agents from all liabilities, claims and expenses arising herefrom; (v) the rates stated above are for only the procedure/diagnosis described, additional treatment or complications from treatment shall be provided at the Provider’s Usual and Customary Rates, unless otherwise agreed to by Provider.
Agreed to by:
_________________________________ _________________________________ _________________________________ |
_________________________________ _________________________________ |