"You agree in order for us to service our account or collect any amount you may oh we may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in a charge to you. We may also contact you by sending text messages or emails, using an email address you provide for us to use. Methods of contact may include using pre-recorded/artificial voice messages and or the use of an automatic dialing service, as applicable. I/we have read this disclosure and agree that the lender/creditor may contact me/us at described above."

In addition, it is the policy of UPG to have a Financial Policy that clearly outlines patient responsibilities. By signing this form, you are acknowledging that you may be responsible for any and all reasonable and customary charges and any non-covered ancillary services. You may also be responsible for out-of-network benefits, late fees, and/or insufficient fund/bounced check fees. Our offices also reserve the right to charge a no-show fee of $25.00 for any no-show appointment. Your co-pay, deductible and any portion of the charges as specified by your insurance plan is due at time of service, a $10.00 fee will be billed to your account if the payment is not received at time of service. You may be responsible for procedures deemed by your insurance as "Not Medically Necessary", or any visit that requires prior authorization or referrals not obtained prior to the visit. It is the patient’s responsibility to ensure that their insurance is updated and active.