North Jersey Hip and Knee Center, P.C.
Aiman Rifai, D.O.
1033 Rt.46 East/Suite A206
Clifton, NJ 07013
Tel: 973-594-8500 Fax: 973-594-8505
AGREEMENT FORM
DATE:________________
PATIENT:___________________ ACCOUNT#:______________ DOS:___________
AUTHORIZES______________________ to deposit insurance checks received
On _______________ account when made out to.
Patient/Policyholder:
Patient Receipt of Checks:
In the even that I receive direct payment of any amounts due to North Jersey Hip and
Knee Center, P.C. and any Explanation of Benefits (EOB) to the extent not sent directly
to North Jersey Hip and Knee Center. I agree to notify North Jersey Hip and Knee
Center, upon receipt of such check and to endorse the check “Pay to the order of North
Jersey Hip and Knee Center,” and immediately mail the check and EOB to North Jersey
Hip and Knee Center, keeping copies of the Check and EOB for my records.
I understand that failure to comply with my responsibilities under this form will result in
my account remaining active. I guarantee payment of all said charges incurred. Interest
of the unpaid balance shall be incurred at a rate of 8% per annum and will accrued 90
days after services are rendered. In the further event that the account must be placed
with an attorney or collection agency to obtain payment, I shall be responsible for all
attorney and collection agency fees incurred.
The undersigned has read and understands the above terms.
Signature:__________________________ Date:__________________
Witness:___________________________ Date:__________________