Worthy Care Concierge Nursing, LLC
Valley Road Wexford PA 15090
Phone (878) 229-2727

I, the above-named patient, understand that I am financially responsible for all services provided to me by Worthy Care Concierge Nursing, LLC.

• I agree to pay for all services provided to me by the healthcare provider or clinic at the time or prior to services rendered.
• I authorize the healthcare provider or clinic to release any necessary information to my insurance company or any other party responsible for payment of my healthcare services.
• I agree to provide the healthcare provider or clinic with updated contact information, including my mailing address, phone number, and email address.
• I understand that failure to pay for services provided may result in the healthcare provider taking legal action to collect payment, and that I may be responsible for any legal fees and expenses incurred by the healthcare provider in such an action.

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Acknowledgment and Agreement

By signing below, I acknowledge that I have read and understand the financial responsibility agreement and agree to comply with its terms.