Royal Oaks OB/GYN
12121 Richmond Avenue, Suite 414
Houston, TX 77082
Phone: 281-496-DRVU (3788)
PATIENT FINANCIAL RESPONSIBILITY ACKNOWLEGEMENT
1. I understand that full payment is due at the time of service.
2. I understand that co-payments and deductibles are due at the time of service.
3. I have the following options to pay for services: cash, bank debit card,
MasterCard, Visa, Discover, or American Express. No checks will be accepted at
4. Even if I do not have health insurance coverage, I will pay 100% of my
anticipated charges out of pocket at the time of service.
5. I understand that there are no payment plans.
6. I will provide the most current and accurate information about myself and my
insurance plan or Medicaid/ Medicare plan. I will update Royal Oaks OB/GYN
immediately of any changes to my coverage and/or contact information (address,
phone number, e-mail, etc.). If my insurance/ Medicaid/ Medicare is temporarily
cancelled, I will call to inform the office of this fact. If I do not notify the office
of my insurance cancellation and do not show for my scheduled appointments (2
or more), I authorize Royal Oaks OB/GYN to close my account and chart.
7. I will not give false information about myself or my health coverage plan. I
understand that I if do this, I will be fired from Royal Oaks OB/GYN as a patient
and be reported to the authorities/ insurance company.
8. I agree to call and cancel/ reschedule my appointment within 24hours in advance
if I am unable to keep that appointment. If I do not notify the office of my
inability to keep my appointment, I agree to pay the full charge of the
appointment. This charge will be billed to me. I understand that my insurance
will not cover this charge.
9. I understand that persistent outstanding balances will be turned over to an outside
10. I will bring my current insurance/ Medicaid/ Medicare card and state/
government issued picture identification (driver’s license, passport, or
identification card) to every office visit.
Patient Name (please print) Witness Name (office staff)
Patient Signature Witness Signature