Patient Financial Responsibilty Please read, print and sign the following and bring to your appointment. Your signature constitutes an agreement to the policies and procedures of our practice. I acknowledge full financial responsibility for services rendered by Dr. William Ingram, D.M.D.. I understand that I am financially responsible for all charges whether or not paid for by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance claim submissions. I assign directly to Dr. Ingram all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am responsible for prompt payment of any portion of the charges not covered by insurance, including deductible and co-pays. I understand payment of copays is expected at time of service, as well as any prior balance I may owe. I agree to all attorney fees and collection costs in the event of default of payment of my charges. _____________________________________________________