I HAVE READ AND/OR BEEN FURNISHED A COPY OF THE "Notice of Privacy Act" for Enterprise Valley Medical Clinic. The information on this form is accurate and complete to the best of my knowledge. I will not hold Enterprise Valley Medical Clinic or any member of the staff responsible for any errors of omission that I may have made in completing this form. Medical Insurance is a contract between the insured and insurance carrier. The patient is responsible for the total fees charged for services rendered at our office. We are happy to bill your insurance. I agree to pay all fees that are incurred during my exam or treatment of the above patient. I also understand that I am responsible for any balance not paid by my insurance carrier.