| Ohio Institute For Comprehensive Pain Management, Inc. |
Mervet K. Saleh, M.D. Board Certified Anesthesia Board Certified Pain Management 1235 E. Alex Bell Road Centerville, Ohio 45459 Tel. (937) 435-6400 Fax (937) 435-4793 |
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| I, understand that if for any reason Workers' Compensation, Medicare, Medicaid, private insurance, or my personal injury case (attorney) does not approve/cover a procedure or office visits, I will be held responsible for the entire cost. | |||||
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____________________________________________________________________________________________________ (Patient/Guardian Signature) (Date) |
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| (Print the form before signing) | |||||
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