This statement template is intended to notify your patient of his or her financial obligations related to your services (including deductibles, co-payments and other insurance requirements), and includes space for acknowledgement by the patient or an authorized representative.
Please note: Please confirm all purchases before you complete them as all sales of this product are final. Upon completion of your order, a link to access your purchase will be sent to the email address you have on file with the Academy. Please be sure your email address is accurate before submitting your order. If you have difficulty with your purchase, please contact firstname.lastname@example.org. Thank you.