FINANCIAL AGREEMENT. In addition to all of Institute of Healthcare, Inc academic standards and policies, I understand that The Institute of Healthcare is not currently recognized with institutional accreditation recognized by the United States Department of Education. Students are not able or eligible to participate in federal financial aid programs in association with the Institute of Healthcare, Inc. With that being said, the applicant will be withdrawn from the course for failure to meet financial obligation. “Prior to signing this enrollment agreement, you must be given a catalog or brochure and a School Performance Fact Sheet, which are encouraged to review prior to signing this agreement. These documents contain important policies and performance data for this institution. This institution is required to have you sign and date the information included in the School Performance Fact Sheet relating to completion rates placement rates, license examination passage rates, and salaries or wages, and the most recent three- year cohort default rate, if applicable, prior to signing this agreement. “As a prospective student, you are encouraged to review this catalog prior to signing an enrollment agreement. You are also encouraged to review the School Performance Fact Sheet, which must be provided to you prior to signing an enrollment agreement.” “I certify that I have received the catalog, School Performance Fact Sheet, and information regarding completion rates, placement rates, license examination passage rates, salary or wage information, and the most recent three-year cohort default rate, if applicable, included in the School Performance Fact sheet, and have signed, initialed, and dated the information provided in the School Performance Fact Sheet.” “I understand that this is a legally binding contract. My signature below certifies that I have read, understood, and agreed to my rights and responsibilities, and that the Institutions cancellation and refund policies have been clearly explained to me.” Applicant Signature Applicant Print Name Date Authorized Employee of Institute of Healthcare, Inc. Signature Print Title Date “NOTICE” “YOU MAY ASSERT AGAINST THE HOLDER OF THE PROMISSORY NOTE YOU SIGNED IN ORDER TO FINANCE THE COST OF THE EDUCATIONAL PROGRAM ALL OF THE CLAIMS AND DEFENSES THAT YOU COULD ASSERT AGAINST THIS INSTITUTION, UP TO THE AMOUNT YOU HAVE ALREADY PAID UNDER THE PROMISSORY NOTE.” TOTAL CHARGES FOR THE CURRENT PERIOD OF ATTENDANCE: $1,595.00 ESTIMATED TOTAL C...
FINANCIAL AGREEMENT. I understand that there is no guarantee of reimbursement or payment from any insurance company or other payer. I understand this Agreement is a contract and that it obligates me to pay all charges for my treatment not paid by my insurer or any other payer source. I understand the Hospital has pre-determined the charges for certain procedures, supplies, and treatments, which these charges are listed in the Hospital’s Chargemaster, and these prices are incorporated by reference into this Contract. I acknowledge it may not be possible to state in advance which specific supplies and services will be part of my treatment. I acknowledge I have the right to receive an estimate of the facility’s average charge for treatment that are frequently performed on in-patient, outpatient, or surgical procedures. If I receive an estimate of charges, I acknowledge that the Hospital is acting in good faith by providing such an estimate. I acknowledge that any estimate is not binding and that the charges I am personally obligated to pay may be more than the estimated charge for my specific treatment. I acknowledge this Contract means I personally have full financial responsibility for, and agree to pay, all charges for the Hospital and of physicians rendering services not otherwise paid by my health insurance or other payer based upon the Hospital’s pre-determined Chargemaster rates. Estimated patient responsibility is due at the time of service or following the medical screening exam. Any remaining charges are due and payable upon receipt of the xxxx. I acknowledge and understand that any refund that I may be owed will first be applied to any outstanding balance, and the remainder will be forwarded to the address on file with the Hospital. If I do not have insurance or I cannot pay my xxxx, I may qualify for financial assistance. I understand that I may be required to submit documentation to determine my eligibility for financial assistance. I understand the hospital may request and use data from third parties such as credit reporting agencies in order to verify demographic data or evaluate financial options. If payment is not made within 180 days after receipt of the xxxx, a delinquent charge or interest at the maximum legal rate may be added. I agree to pay all legal expenses necessary for the collection of any debt or any action on this Contract. I hereby acknowledge and agree that the Hospital has not made any implied representations about the charges I am personally obli...
FINANCIAL AGREEMENT. I will give a nonrefundable deposit of $100 at the first team meeting to solidify my commitment to this trip. • I understand that I am financially responsible for the full trip cost and agree to raise funds or self-fund as necessary to meet this goal. • Once airline tickets have been purchased, I am responsible for 100 percent of the ticket price, even if I have to withdraw from the global(x) trip. • I agree to meet fundraising deadlines as determined by global(x), and I understand that failure to meet one of the deadlines may result in being unable to go on the trip. • In the event I am unable to participate in the global(x) trip, I understand that all funds raised are nonrefundable and nontransferable to a future global(x) trip. • I understand that any funds raised over the required amount for my trip are nonrefundable and will be used to cover overall trip costs and/or international projects as determined by the global(x) staff. Initial here: TALENT RELEASE I, hereby permit global(x) and The 410 Bridge, Inc. (The 410 Bridge) to use any audio, video, written, or pictorial footage of myself taken while on this global(x) trip for future promotions of global(x) and the 410 Bridge. I understand that neither global(x) nor The 410 Bridge will use any of this footage for any purposes or organizations outside of marketing for global(x) and The 410 Bridge, nor will they sell or release this material to any outside party. Initial here: SIGNATURE PAGE I have read and agree to the following: global(x) Code of Conduct, Team Agreement, Financial Agreement, and Talent Release. Signed: Date: Name (please print): MEDICAL AND LIABILITY RELEASE global(x), operated by North Point Ministries, Inc., under the supervision of the staff and volunteers of North Point Community Church, Buckhead Church, Browns Bridge Church, Woodstock City Church, Gwinnett Church, and/or Decatur City Church, along with The 410 Bridge, Inc. (The 410 Bridge) require the completion and acceptance of a medical and liability release prior to participation in a global(x)/410 Bridge trip. Trip Dates: Country:
FINANCIAL AGREEMENT. During the term of this contract, Party A shall abide by the following financial indicators: /
FINANCIAL AGREEMENT. I will give a nonrefundable deposit of $100 at the first team meeting to solidify my commitment to this trip. • I understand that I am financially responsible for the full trip cost and agree to raise funds or self-fund as necessary to meet this goal. • Once airline tickets have been purchased, I am responsible for 100 percent of the ticket price, even if I have to withdraw from the global(x) trip. • I agree to meet fundraising deadlines as determined by global(x), and I understand that failure to meet one of the deadlines may result in being unable to go on the trip. • In the event I am unable to participate in the global(x) trip, I understand that all funds raised are nonrefundable and nontransferable to a future global(x) trip. • I understand that any funds raised over the required amount for my trip are nonrefundable and will be used to cover overall trip costs and/or international projects as determined by the global(x) staff. Initial here: I, hereby permit global(x) and North Point Ministries Inc. (NPMI) to use any audio, video, written, or pictorial footage of myself taken while on this global(x) trip for future promotions of global(x) and NPMI. I understand that neither global(x) nor NPMI will use any of this footage for any purposes or organizations outside of marketing for global(x) and NPMI, nor will they sell or release this material to any outside party. Initial here: I have read and agree to the following: global(x) Code of Conduct, Team Agreement, Financial Agreement, and Talent Release.
FINANCIAL AGREEMENT. The following is a description of financial responsibilities of the Individual Activity Applicant and the co-provider(s): Individual Activity Applicant Representative, Name and official title: ___________________________________________________________________________________ Signature of Individual Activity Applicant Representative: _____________________________________ Name of Individual Activity Applicant organization: ___________________________________________________________________________________ Co-Provider Representative Name and official title: __________________ _________________ Signature of Co-Provider Representative: _________________________________________________ Co-Provider Name/Agency: ___________________ _____ _______ Address: ___________________________________________________________________________ Phone: __ Email address________________________________________
FINANCIAL AGREEMENT. By signing and submitting this form, I agree to the following payment and cancellation policies:
FINANCIAL AGREEMENT. For the services to be rendered, I agree to accept full financial responsibility for the patient’s account in accordance with the regular rates and terms of Stanford Medicine Partners. This includes financial responsibility for all deductibles and co-payments that may be required by the patient’s insurance or health plan. This also includes services or supplies not covered by the patient’s health insurance plan and/or Medicare. Should the patient’s account(s) be referred to an attorney or a collection agency for collection, I further agree to pay actual attorneys’ fees and lawsuit-related expenses incurred in addition to other amounts due. When the services are to be billed to insurance, a health plan or another payment source, paragraphs 6 (Contracted Health Plan Patients and Other Sources) and 7 (Assignment of insurance Benefits) will also apply.
FINANCIAL AGREEMENT. As a courtesy to our patients, we will file insurance benefits upon your behalf. However, it must be stressed that your insurance is a contract between you, your employer and the insurance company. Our office will prepare the necessary insurance forms as a courtesy for our patient’s and accept assignment of benefit payment from most insurance companies, reduc ing the immediate out of pocket expenditures. However, we will collect the estimated portion of your fee at the time that services are rendered, regardless of who accompanies the patient on the day of his/her appointment. Though estimated amounts are collected on the date that services are rendered, any differences that may exist after your insurance company has paid their allowable amount will be billed to you for immediate payment. While we will always attempt to help each patient receive the maximum benefits available, we will not be involved in disputes between you (the patient) and your insurance company regarding covered charges, secondary insurance, reasonable and customary determinations, etc. Patients who do not carry dental insurance are responsible for the entire balance of any procedure rendered; due the date of service such procedures are rendered. Any estimated fee presented for treatment will be extended for a period of 90 days from the date that the treatment estimate is presented, unless prior arrangements or exceptions are approved by our office. Any insurance claims that have not been paid within 60 days will become the guarantor’s responsibility, in which you the guarantor will receive notice from our office. Any outstanding balances will be billed in way of a monthly statement of services, at which remittance is due upon receipt. Accounts receiving multiple statements may be accessed with a monthly statement fee of $5. Any account which is sent a third statement with no previous response will be considered a final notice. All accounts will be considered delinquent after 90 days and placed with an outside third-party company for processing and collection. The guarantor and/or patient agrees to pay any cost accrued in collecting amounts owing, including court cost, attorneys’ fee, collection agency fees and collection cost not to be more than fifteen percent (15%) of the unpaid debt. Upon this action, the patient and/or their family may be dismissed from our practice. For the convenience of our patients, we offer several methods of payment including cash, check, credit card (Visa, M...
FINANCIAL AGREEMENT. As noted above, if Premiere Speech and Hearing is contracted with your insurance company, we will file your insurance claims for you and agree to accept assignment based on the insurance companies fee schedule. You understand that the following conditions apply: • You understand that you are ultimately responsible for any portion of your bill that your insurance company does not pay. • Payment is expected within thirty (30) days from receipt of billing. • You understand that regardless of the type of insurance coverage you may have, policies are a contract between yourself and the insurance carrier. Furthermore, you are ultimately responsible for payment. • You accept responsibility for providing us with a current, valid insurance card for the purposes of identification and verification of your insurance coverage. If your claim is denied because of lack of coverage or because your insurance company does not pay for the services rendered, you will be responsible for the entire balance on your account. • You will be responsible for the collection of any copayments, deductibles and co- insurance amounts as deemed by the insurance company. The following codes will be used for insurance billing: Procedural Code: 92507 Diagnostic Code: Authorization for Payment/Assignment of Benefits: You authorize Premiere Speech and Hearing to bill services you receive payment from the payer source confirmed with you at the time of admission. You hereby request and authorize payment directly to Premiere Speech and Hearing of any Medicare, insurance or third party benefits otherwise payable to you for services. Co-payments, deductibles, co- insurance and any supplies that insurance does not cover are the responsibility of the patient and are due at the time of visit or it will be billed directly to the patient. The insurance company stipulates that there is no guarantee of payment. Claims submitted will be paid in accordance with the member’s eligibility status and all benefit plan provisions and limitations at the time the service/procedure is actually rendered. You understand that it is your responsibility to notify Premiere Speech and Hearing of any and all changes in payer sources for these services. You understand that you are financially responsible to Premiere Speech and Hearing for charges not covered by this assignment and consistent with the state and federal law. Premiere Speech and Hearing may release any information concerning you in order to support any request fo...
