I do hereby understand that my personal insurance CA with Physician Services gets paid upon my payment of invoice. All invoices will be faxed either on the 1st or the 15th of each month and all invoice payments are due in Physician Services office at the above in 10 days of invoice being faxed.

I do understand that if invoice is not received then all work on my account will cease until invoice is paid. If payment of invoice is late a late fee of 10% of invoice amount will be assessed. If my check bounces I agree to pay a $50 bounced check fee as well as I understand that until I make my check good and pay the $50 bounced check fee all work on my account will cease.

I do understand this invoice payment policy and will comply with the terms.

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Doctors signature and date