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Patient Responsible Party

Click here if you are the responsible party who is wholly or in part responsible for paying the services fees

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Responsible Party's {{guest.DATEOB.CustomLabel}}(MM/DD/YYYY)^* Patient's {{guest.DATEOB.CustomLabel}} (MM/DD/YYYY)^*

{{guest.DATEOB ? guest.DATEOB.CustomHelpText : 'Date of Birth is required'}}

Future date entered.Please enter a valid date.

DOB to be greater than 12/31/1899.

{{guest.ACCNO.CustomLabel}}^*

Invalid Account number

{{guest.ACCNO ? guest.ACCNO.CustomHelpText : 'Account Number is Required'}}

{{form.IsGuarantor=='true'? responsibleParty:"Patient's"}} {{guest.SSN.CustomLabel}}^*

Invalid SSN number

{{form.IsGuarantor=='true'? responsibleParty:"Patient's"}} {{guest.LNAME.CustomLabel}}^*

{{form.IsGuarantor=='true'? responsibleParty:"Patient's"}} {{guest.LNAME ? guest.LNAME.CustomHelpText: 'Last Name is Required'}}

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Phone Number

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