Patient Financial Responsibility Form


Robert J. Kaplan
Twin Rivers Podiatry – Easton
1901 Hay Terrace
Easton, PA 18042
Patient Financial Responsibility Form
In the event that any unpaid balance is placed for collections with any 3
party collection agency and/or
with an attorney to obtain judgment or otherwise satisfy payments of the account, all collection fees will
be added to the total amount due. This amount shall include any costs incurred directly or indirectly by
the provider to collect amounts owned by under the agreement, costs included by not limited to,
collection fees, attorney fees, court fees, sheriff fees, late fees, accrued fees, etc. These cost and fees
reflect that actual costs incurred.
I understand the above terms and agree, on my own accord on these terms, as indicated by my
signature below.
Patient/Grantor Signature:____________________________
Patient Name Printed:________________________________
Rjk/blb 4/16


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