My Signature below indicates that, as the cardholder, I agree to authorize payment for services rendered by the service provider. By signing I agree to accept total responsibility of the bill, in which total amounts may reflect 1. The full amount owed for service, 2. Copayment of insurance benefits, 3. Payment of any applicable missed appointment fees, or 4. Other payment arrangements agreed upon by the patient, cardholder, and/or service provider.
