| I have informed Mercer-Bucks Orthopaedics that the treatment/services I am receiving starting the below entered date, are not the result of an automobile accident. The injuries for which I am seeking treatment/services do not arise out of the ownership, operation, maintenance, use of an automobile, entering into, alighting from an automobile or as a pedestrian. I understand that by my notifying Mercer-Bucks Orthopaedics that the injuries are not automobile related, no notification or claim will be sent to my automobile insurance company. Therefore, any bills incurred but not covered by my personal health insurance will be my personal responsibility and obligation to pay. Payment is expected upon receipt of services. We at Mercer-Bucks Orthopaedics ask that you sign this document only after any questions you may have concerning its content have been answered to your satisfaction and you understand your obligation to pay for any unpaid services by your insurance carriers. |
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