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This agreement explains your financial responsibility for diagnostic imaging and related services provided by TruePath Imaging, LLC.

1. Responsibility for Payment

By submitting this form, you agree you are personally and fully responsible for payment of all charges for services you request or receive from TruePath Imaging. This includes services not covered by insurance and those provided on a private-pay basis. Your responsibility applies even if another party, an insurer, an employer, or a legal claim is involved.

2. No Contingency on Claims or Insurance
Payment is not dependent on any lawsuit, settlement, judgment, insurance determination, or third-party recovery. Insurance verification is not a guarantee of payment. You remain responsible for all balances not paid for any reason.

3. Private Pay Services
For private-pay services, payment is due prior to or at the time of service, unless a written payment arrangement is in place.

4. Personal Injury and Attorney-Involved Cases
If services relate to an injury or legal claim, you remain financially responsible for all charges, even if settlement funds are delayed, reduced, disputed, denied, or unavailable. Any medical lien provides an additional method of payment and does not replace or limit your personal responsibility under this agreement.

5. Changes in Legal Representation
You agree to notify TruePath Imaging in writing within five business days of any change in legal representation or termination of representation. Failure to provide timely notice does not relieve you of payment responsibility and does not delay or invalidate billing, lien enforcement, or collection activity.

6. Authorization to Charge Payment Method
You authorize TruePath Imaging to charge the payment method you provide for approved services, missed appointments, late cancellations, and outstanding balances owed under this agreement. Charges reflect fees disclosed to you prior to service.

7. Billing Information Authorization

You authorize TruePath Imaging to share billing records, invoices, and related payment information with attorneys, insurers, and third parties involved in payment or claim coordination.

8. Disputes and Chargebacks
You agree to contact our office before initiating a charge dispute. Chargebacks do not release you from payment responsibility for services rendered.

9. Non-Payment and Collections
Unpaid balances are subject to collection activity consistent with applicable law. You are responsible for reasonable costs incurred in collecting unpaid balances.

10. No Waiver of Legal Rights
For private-pay services, payment is due prior to or at the time of service, unless a written payment arrangement is in place.

11. Electronic Signature and Consent
You agree that this submission serves as your electronic signature. You acknowledge that you reviewed and accepted these terms before submitting payment information. This agreement is legally binding.

12. Entire Agreement
This agreement applies only to financial responsibility for services provided by TruePath Imaging. It does not modify clinical care, diagnostic findings, or medical opinions.

I have read and agree to the Payment Responsibility Agreement and authorize the charging of my payment method.

I acknowledge that by clicking Submit, you confirm your intent to enter into a legally binding agreement and authorize payment as described above.