Your signature below will acknowledge that you have read and/or received copies of both the Center for Fetal Medicine and Women’s Ultrasound Financial Policy and Notice of Privacy Practices. In addition, I hereby authorize Center for Fetal Medicine and Women’s Ultrasound to bill my insurance company and receive payment from them on my behalf. I acknowledge, however, that I am responsible for payment of my account and any and all charges associated with its collection.

In the event any balance is not paid as agreed within 60 days of the billing date on the first statement, the undersigned agrees to pay a collection fee equal to 30% of unpaid balance.

I acknowledge receipt of this Insurance Information/Financial Policy and will abide by these requirements.
If you have any questions, please call us at (323) 857-1952.We appreciate your cooperation on this very important matter.