Patient Financial Agreement

I agree to pay the Hearing Wellness Center for all services provided to me by the Hearing Wellness Center and others for whom the Hearing Wellness Center collects bills at the regular rates. This includes services which, for any reason, are not paid by insurance, government programs or other third party sources. I understand that any self-pay portion of my office bill is due upon notification. Until my accounts are finally settled, I give my direct consent to receive communications regarding my accounts to any servicers and any debt collectors of my accounts (“Affiliates”), by various means, including, without limitation an automatic telephone dialing system, text message, email or an artificial or prerecorded voice, through any medium I provide to you, including, without limitation any cellular phone, landline, email address, fax number, text number or any other form of contact information I directly or indirectly provide to you or your Affiliates (“Contact Information”). I further agree to pay reasonable attorney’s fees and all costs of collection in the event my account is turned over to an attorney or collection agency.