Commonwealth Urology
JOHN J. BASILE, MD, PC
SUNIL V. PATEL, MD
Adult and Pediatric Urology

Uninsured Responsibility Form


I, _________________________________ am currently uninsured. I understand that I am expected to pay the full amount owed prior to the time of service today. If I cannot pay the full amount at this time, I agree to pay half and to make arrangements (prior to being seen by the doctor today) to pay the balance in full within six months.


Signature: __________________________________


Date: ______________________________


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Commonwealth Urology
JOHN J. BASILE, MD, PC
SUNIL V. PATEL, MD
3020 Hamaker Court, Suite B-111
Fairfax, Virginia 22031-2220
Tel: 703.876.0288
Fax: 703.876.0290
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