FINANCIAL POLICY AGREEMENT Sample Clauses

FINANCIAL POLICY AGREEMENT. All co-pays and past due balances are due and payable at the time of service unless prior arrangements have been made. Your insurance company requires us to collect your co-pay at the time of your visit. It is not our policy to bill you for your co-pay; if not paid at the time of service a $10 fee will be assessed. Payment may be made with cash, check, Visa or MasterCard. We do not take Discover or American Express. REFERRALS If your insurance company requires a referral be sure you request this from your primary doctor. If you are unsure if you need an insurance referral, call your insurance company. Please allow enough time for your primary care office to process the referral prior to your visit. You will be responsible for any balance on claims denied due to no referral.
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FINANCIAL POLICY AGREEMENT. Welcome and thank you for selecting the East Carolina University School of Dental Medicine as your dental provider. We are committed to providing you and your family with the best possible service and appreciate the trust you have placed in our team of professionals. Before we perform any service, an explanation of the recommended treatment, treatment options, and a reasonable estimate of treatment fees will be presented to you for your approval. We ask that you carefully review and sign our Financial Policy Agreement before beginning treatment, and encourage you to communicate with us regarding any problems that may affect your ability to afford care.
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FINANCIAL POLICY AGREEMENT. Thank you for choosing Xx. Xxxx for your medical care. We are committed to providing you with quality, personal health care. As a part of our professional relationship, it is important that you have an understanding of our financial policy. Other than for true medical emergencies, agreement with this policy is required for all medical care. Violation of this policy will result in a patient termination letter. Unfortunately, there will be no exceptions. Co-Payment Policy • All co-payments, current balances, co-insurance and deductibles are due at the time of services being rendered and is required by your insurance to be paid at each visit. • If you do not know your co-pay we will collect a minimum fee of $30.00 or whatever amount we find when contacting your insurance.Our billing department will xxxx or credit your account accordingly after your insurance pays their portion.
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FINANCIAL POLICY AGREEMENT. Thank you for choosing us as your health care provider. We are committed to your successful treatment. We require all patients to read and sign our Financial Policy prior to receiving any services. It is the policy of this clinic(s) that all outstanding balances are to be paid in full upon receipt of a current statement. Any patients that no show for an appointment without contacting the clinic will be charged a No Show Fee of $25.00. Patients will be charged a fee of $30.00 for any checks returned for non-sufficient funds. We accept cash, checks and Visa, MasterCard, or Discover.
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FINANCIAL POLICY AGREEMENT. The School Commission achieved consensus on this Financial Policy Agreement on , 2015, as evidenced by the signatures below, which constitute a quorum as described in Article VI of the Commission’s Bylaws. PRINCIPAL PASTOR CHAIR VICE-CHAIR CO-SECRETARY CO-SECRETARY MEMBER MEMBER MEMBER MEMBER MEMBER FINANCIAL POLICY AGREEMENT The Finance Committee achieved consensus on this Financial Policy Agreement on , 2015, as evidenced by the signatures below. PASTOR CHAIR VICE-CHAIR SECRETARY MEMBER MEMBER MEMBER MEMBER MEMBER MEMBER MEMBER FINANCIAL POLICY AGREEMENT FORM 2015-2016 Please sign this Agreement and return this page to the school office no later than July 10, 2015. Please retain a copy of the Financial Agreement Policy for your personal records. I have read the Financial Policy Agreement and agree to abide by the guidelines set forth herein. Family Name (please print): Parent(s) Signature(s):
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FINANCIAL POLICY AGREEMENT. The purpose of this document is to inform our patients about Retina Consultants Financial Policy. We ask that you read and acknowledge receipt of this information which will be kept in your electronic file. Thank you. If you have insurance, we will bill the plan based on our contract status with the insurance plan. Accurate and current insurance information is necessary to ensure prompt payment by your health plan. Failure to keep us informed of the appropriate insurance information for claims submissions may result in you receiving a bill for these services. As a courtesy, we may bill your secondary insurance plans; however, you are responsible for any balance unpaid after 60 days regardless of status from your insurance plan. For patients that require treatment involving high-cost injectable medications, we will work with you to enroll you in a copay assistance program. If you either do not qualify, or you chose not to enroll in the program, you will be required to pay your coinsurance for the treatment at each visit. Balances will not be carried on account for these services. Billing staff will assist you in this regard. Patients without insurance, or patients with non-contracted insurance, are required to pay at the time services are provided or make other arrangements with our billing staff Billing department direct phone number is 000-000-0000. Copays are due at the time of service, amount as defined by your insurance plan. We verify eligibility prior to appointments to ensure accuracy of copay amount due. The amount of your copay we collect may vary from what is assessed by your insurance plan. There may be additional patient responsibility balances owing and you will be billed for those amounts. Accounts with a credit balance will be processed when a patient has completed care in our clinic. As a specialty group, insurance referrals are often required by your insurance plan. We will make every effort to obtain a referral in advance of your appointment. However, based on the agreement between you and the insurance plan that you have selected, it is your responsibility to know the referral requirements of your plan and verify that your services are authorized by the health plan. While we do accept personal checks, any bank returned check will be assessed a $35.00 fee and charged to your patient account. You may be requested to pay balances by cash, debit, or credit card only for future services. Accounts that have an outstanding balance after 90 days...
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FINANCIAL POLICY AGREEMENT. Private Insurance - As a courtesy to our patients, we file most insurances. Your insurance must be current and verifiable at the time of your visit. Payment assignation must be made to this office. Please be aware that some or perhaps all of the services rendered may or may not be covered, including vaccines. If your insurance company denies payment, you will be billed for any balance due. We cannot file your insurance unless you have your card with you. If you do not have your insurance card with you, you can either reschedule your visit or you can be seen as a “self-pay” for that particular visit. If you do not submit the correct insurance card at the time of your visit, you will be considered self-pay and any services rendered on the day of your visit will be your responsibility. If your insurance company fails to pay their portion of outstanding charges after 90 days, the account will be automatically turned over to you and the balance due will become your responsibility.
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FINANCIAL POLICY AGREEMENT. RE: Insurance Coverage For those patients who are covered by private insurance, we are pleased to extend the courtesy of billing your insurance company for you. In order to provide this service for your, we must have complete insurance information and confirmation of your coverage. We ask that you fill out all forms which will give us the necessary information. It is our policy that anything not covered by insurance is to be paid for that time of service. If your insurance company has not paid within 90 days of billing, the balance will become the responsibility of the patient. Please remember that insurance is an agreement between the insured and insurer. Therefore, if any problem arises with the carrier, we will ask that you handle it with the insurance company. Our office will provide your insurance company with any additional information which may become necessary for resolution. I understand and agree to honor my financial commitment to the office of Xxxxxx Xxxxxxxx, DMD.
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Related to FINANCIAL POLICY AGREEMENT

  • 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 CHARGES FOR THE ENTIRE EDUCATIONAL PROGRAM: $1,595.00 THE TOTAL CHARGES THE STUDENT IS OBLIGATED TO PAY UPON ENROLLMENT: $1,595.00 SCHOOL PERFORMANCE FACT SHEET EMERGENCY MEDICAL TECHNICIAN PROGRAM: 4, 8 and 12 WEEK COURSES OFFERED ON-TIME COMPLETION RATES (GRADUATION RATES) Includes data for the two calendar years prior to reporting. Calendar Year Number of Students Who Began the Program Students Available for Graduation Number of On- Time Graduates On-Time Completion Rate 2018 N/A N/A N/A N/A 2019 N/A N/A N/A N/A Students Initials: Date: Initial only after you have had enough time to read and understand the information Job Placement Rates (includes data for the two calendar years prior to reporting) Calendar Year Number of Students Number of Graduates Graduates Available for Employment Graduates Employed in the Field Placement Rate % Employed in the Field Who Began Program 0000 X/X X/X X/X X/X X/X 2019 N/A N/A N/A N/A N/A You may obtain from the institution a list of the employment positions determined to be in the field for which a student received education and training. Please request from Administration. Gainfully Employed Categories (includes data for the two calendar years prior to reporting) Part-Time vs. Full-Time Employment Calendar Year Graduate Employed in the Field 20-29 Hours Per Graduates Employed in the Field at Least 30 Hours Per Week Total Graduates Employed in the Field Week 2018 N/A N/A N/A 2019 N/A N/A N/A Single Position vs. Concurrent Aggregated Position Calendar Year Graduates Employed in the Field in a Single Graduates Employed in the Field in Concurrent Aggregated Positions Total Graduates Employed in the Field Position 2018 N/A N/A N/A 2019 N/A N/A N/A Self-Employed / Freelance Positions Calendar Year Graduates Employed who are Self- Employed or Working Freelance Total Graduates Employed in the Field 2018 N/A N/A 2019 N/A N/A Institutional Employment Calendar Year Graduates Employed in the Field whoare Employed by the Institution, anEmployer Owned by the Institution, or an Employer who Shares Ownership with the Institution. Total Graduates Employed in the Field 2018 N/A N/A 2019 N/A N/A Student’s Initials: Date: Initial only after you have had sufficient time to read and understand the information. License Examination Passage Rates (includes data for the two calendar years prior to reporting) Calendar Year Number of Graduates in Calendar Year Number of Graduates Taking Exam Number Who Passed First Available Exam Exam Number Who Failed First Available Exam Passage Rate 0000 X/X X/X X/X X/X X/X 2019 N/A N/A N/A N/A N/A Licensure examination passage data is not available from the state agency administering the examination. We are unable to collect data from graduates. Student’s Initials: Date: Initial only after you have had sufficient time to read and understand the information. Salary and Wage Information (includes data for the two calendar years prior to reporting) Annual salary and wages reported for graduates employed in the field. Calendar Year Graduates Available for Employment Graduates Employed in Field $20,001 - $25,000 $35,001 - $40,000 $40,001 - $45,000 $45,001 - $50,000 No Salary Information Reported 2018 N/A N/A N/A N/A N/A N/A N/A 2019 N/A N/A N/A N/A N/A N/A N/A A list of sources used to substantiate salary disclosures is available from the school Student’s Initials: Date: Initial only after you have had sufficient time to read and understand the information.

  • Renewal Policies Not less than thirty (30) days prior to the expiration date of each insurance policy required pursuant to the Insurance Agreement, Mortgagor will deliver to Mortgagee either an appropriate renewal policy (or a certified copy thereof), together with evidence satisfactory to Mortgagee that the applicable premium has been prepaid.

  • Financial Instruments Not applicable

  • Policy Statement The RSU Award grant the Company is making under the Plan is unilateral and discretionary and, therefore, the Company reserves the absolute right to amend it and discontinue it at any time without any liability. The Company, with registered offices at Xxx Xxxxxx Xxxxxxxxx, #00-00, Xxxxxxxxx 000000, is solely responsible for the administration of the Plan, and participation in the Plan and the grant of the RSU Award do not, in any way, establish an employment relationship between the Participant and the Company since he or she is participating in the Plan on a wholly commercial basis and the sole employer is Availmed Servicios S.A. de C.V., Grupo Flextronics S.A. de C.V., Flextronics Servicios Guadalajara S.A. de C.V., Flextronics Servicios Mexico S. de X.X. de C.V. and Flextronics Aguascalientes Servicios S.A. de C.V., nor does it establish any rights between the Participant and the Employer. Plan Document Acknowledgment. By accepting the RSU Award, the Participant acknowledges that he or she has received copies of the Plan, has reviewed the Plan and the Agreement in their entirety, and fully understands and accepts all provisions of the Plan and the Agreement. In addition, the Participant further acknowledges that he or she has read and specifically and expressly approves the terms and conditions in the Nature of Grant section of the Agreement, in which the following is clearly described and established: (i) participation in the Plan does not constitute an acquired right; (ii) the Plan and participation in the Plan is offered by the Company on a wholly discretionary basis; (iii) participation in the Plan is voluntary; and (iv) the Company and any Parent, Subsidiary or Affiliates are not responsible for any decrease in the value of the Shares acquired upon vesting of the RSU Award. Finally, the Participant hereby declares that he or she does not reserve any action or right to bring any claim against the Company for any compensation or damages as a result of his or her participation in the Plan and therefore grants a full and broad release to the Employer, the Company and any Parent, Subsidiary or Affiliates with respect to any claim that may arise under the Plan.

  • General Policies (a) The evaluated job rate arrived at through official evaluation by the Joint Job Evaluation Board will be final and binding upon both parties to the Labour Agreement unless review has been requested as provided in Section 3(a)(ii)(c) or 3(a)(ii)(g). In case of such review the decision of the Job Evaluation Directors or, where appropriate the Independent Review Officer shall be final and binding upon both parties. Where a number of appeals indicate a problem within a job field, the Directors shall refer such problems to the Administrative Committee for final determination.

  • Renewal Policy The renewal policy for your accounts is stated in the Rate Schedule. For accounts that automatically renew for another term, you have a grace period of seven (7) days after maturity in which to withdraw funds in the account without being charged an early withdrawal penalty.

  • Reporting Arrangements The States will report against the agreed milestones during the operation of this Agreement, as set out in Part 4 – Project Milestones, Reporting and Payments.

  • FINANCIAL AID I understand that aid described as “estimated” on my Financial Aid Award does not represent actual or guaranteed payment, but is an estimate of the aid I may receive if I meet all requirements stipulated by that aid program. In particular, in order to earn all financial aid awarded to me, I must attend and complete the required portion of the term in which I am enrolled per federal financial aid regulations. I understand that my Financial Aid Award is contingent upon my continued enrollment and attendance in each class upon which my financial aid was calculated. If I drop, withdraw, or fail to attend any class before completion, I understand that my federal financial aid will decrease and some or all of the aid awarded to me may be revoked. If some or all of my financial aid is revoked because of any of the above conditions, I agree to repay all aid that was disbursed to my account which resulted in a credit balance that was refunded to me. In addition, any undisbursed financial aid will either be returned to the Department of Education or credited to my account according to federal financial aid regulations. If any financial aid adjustments result in an outstanding balance, I will be responsible for any payment due to CCAC within 30 days. I agree that the financial aid that I am awarded will pay any and all charges billed to my account at CCAC such as tuition, fees, meal plans, student health insurance, parking permits, service fees, fines, bookstore charges, or any other amount, in accordance with the terms of the aid. Federal Aid: I understand that any federal Title IV financial aid that I receive, except for Federal Work Study wages, will first be applied to any outstanding balance on my account for tuition and fees. Title IV financial aid includes funds from the Pell Grant, Supplemental Educational Opportunity Grant (SEOG), Direct Xxxxxxxx Loans, and Direct PLUS Loans. I authorize CCAC to apply my Title IV financial aid to other charges billed to my student account such as student health insurance, parking permits, bookstore charges, service fees and fines, and any other education related charges. I further understand that this authorization will remain in effect until I rescind it, and that I may withdraw it at any time by initiating written contact to the Executive Director of Financial Aid and the Bursar to make arrangements to pay any outstanding charges that remain. State Aid: All state aid withdrawal regulations are governed by the rules of the state which granted the funds. Foundation, External Scholarships and/or Grants: I understand that all external scholarships and/or grants awarded to me by outside and/or institutional sources will be credited to my student account and applied toward any outstanding balance. I further understand that my receipt of a prize, award, scholarship or grant is considered a financial resource according to federal Title IV financial aid regulations, and may therefore reduce my eligibility for other federal and/or state financial aid (i.e., loans, grants, Federal Work Study) which, if already disbursed to my student account, must be reversed and returned to the aid source. Return of scholarship funds are at the discretion of the scholarship donor.

  • Financial Ability Each of the Buyer Parties acknowledges that its obligation to consummate the transactions contemplated by this Agreement and the Brewery Transaction is not and will not be subject to the receipt by any Buyer Party of any financing or the consummation of any other transaction other than the occurrence of the GM Transaction Closing and, in the case of the Brewery Transaction, the consummation of the transactions contemplated by this Agreement. The Buyer Parties have delivered to ABI a true, complete and correct copy of the executed definitive Second Amended and Restated Interim Loan Agreement, dated as of February 13, 2013, among Bank of America, N.A. (“Bank of America”), JPMorgan Chase Bank N.A. (“JPMorgan”) and CBI (collectively, the “Financing Commitment”), pursuant to which, upon the terms and subject to the conditions set forth therein, the lenders party thereto have committed to lend the amounts set forth therein (the “Financing”) for the purpose of funding the transactions contemplated by this Agreement and the Brewery Transaction. The Buyer Parties have delivered to ABI true, complete and correct copies of the fee letter and engagement letters relating to the Financing Commitment (redacted only as to the matters indicated therein), the Financing Commitment has not been amended or modified prior to the date of this Agreement, and, as of the date hereof, the respective commitments contained in the Financing Commitment have not been withdrawn, terminated or rescinded in any respect. There are no agreements, side letters or arrangements to which CBI or any of its Affiliates is a party relating to the Financing Commitment that could affect the availability of the Financing. The Financing Commitment constitutes the legally valid and binding obligation of CBI and, to the Knowledge of CBI, the other parties thereto, enforceable in accordance with its terms (except as such enforceability may be limited by bankruptcy, insolvency, fraudulent conveyance, reorganization, moratorium and other similar Laws of general applicability relating to or affecting creditors’ rights, and by general equitable principles). The Financing Commitment is in full force and effect and has not been withdrawn, rescinded or terminated or otherwise amended or modified in any respect, and no such amendment or modification is contemplated. Neither CBI nor any of its Affiliates is in breach of any of the terms or conditions set forth in the Financing Commitment, and assuming the accuracy of the representations and warranties set forth in Article 4 and performance by ABI of its obligations under this Agreement and the Brewery SPA, as of the date hereof, no event has occurred which, with or without notice, lapse of time or both, would reasonably be expected to constitute a breach, default or failure to satisfy any condition precedent set forth therein. As of the date hereof, no lender has notified CBI of its intention to terminate the Financing Commitment or not to provide the Financing. There are no conditions precedent or other contingencies related to the funding of the full amount of the Financing, other than as expressly set forth in the Financing Commitment. The aggregate proceeds available to be disbursed pursuant to the Financing Commitment, together with available cash on hand and availability under CBI’s existing credit facility, will be sufficient for the Buyer Parties to pay the Purchase Price hereunder and under the Brewery SPA and all related fees and expenses on the terms contemplated hereby and thereby in accordance with the terms of this Agreement and the Brewery SPA. As of the date hereof, CBI has paid in full any and all commitment or other fees required by the Financing Commitment that are due as of the date hereof. As of the date hereof, the Buyer Parties have no reason to believe that CBI and any of its applicable Affiliates will be unable to satisfy on a timely basis any conditions to the funding of the full amount of the Financing, or that the Financing will not be available to CBI on the Closing Date.

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