FINANCIAL RESPONSIBILITY AGREEMENT. Pure Pediatric Therapy is committed to providing you with the best possible care. In order to achieve this goal, we need your assistance and your understanding of our payment policies. Please read through this notice and initial where applicable. If you have any additional questions, please contact your insurance company prior to arriving to your scheduled appointment. Please initial the statements and sign below indicating your understanding of the following: It is your responsibility to contact your insurance company prior to receiving services. As a courtesy to our clients, Pure Pediatric Therapy, Inc. will also call your insurance company to determine your therapy benefits and coverage. Medical insurance companies may initially state that they cover therapy. However, this is not a guarantee and they may deny services at any time. If this occurs, Pure Pediatric Therapy, Inc., will make up to ONE attempt to submit your child’s claims to your insurance company. After the initial attempt, we will bill you the full amount for the services provided and you will be responsible for this amount. It is your responsibility to notify Pure Pediatric Therapy, Inc. of any insurance policy or benefit changes with regards to your child’s services. All parents are expected to contact their insurance company and verify benefits with regards to occupational, physical and speech therapy services. Please ask specifically about any “exclusions” or “limitations” to therapy benefits. This quote of benefits from your insurance company is not a guarantee of payment. Deductibles and co-payments are due at the time therapy services are rendered. If your primary or secondary insurance company makes payment to you (personally) and not to our office, due to contractual obligations, you are responsible for the entire balance between the amount paid by your insurance and the total allowable amount billed, per date of service. This includes amounts applied to your individual or family deductible, and is due upon receipt. If payment is not made to your account within 60 days, your child’s services will be placed on hold until the balance is paid in full. I understand that failure to make payment towards my account will result in Pure Pediatric Therapy sending the account over to a 3rd party collections agency at which time a service charge of 50% of the owed amount will be added to the original owed amount. I have read and understand the Financial Responsibility Agreement. I hereby accep...
FINANCIAL RESPONSIBILITY AGREEMENT. As a courtesy AGM Physical Therapy will make every reasonable attempt to call my insurance to inquire about my outpatient physical therapy benefits. AGM Physical Therapy is not responsible for information obtained from the insurance company that is incorrect or missing information. AGM Physical Therapy advises me to contact my insurance company to obtain my benefit details. I understand and agree it is my responsibility to recognize the therapist is contracted with my insurance and I have verified the therapist is an ‘In Network Provider’ through my insurance. If the therapist is not contracted and is considered an ‘Out of Network Provider’, my insurance benefits may be reduced or denied and I will become financially responsible for any unpaid amounts. Many insurance companies have additional stipulations that may affect my coverage. I understand I am responsible for all fees regardless of insurance coverage. My health insurance policy is a contract between me and my Health Insurance Company or employer. It is my responsibility to know if my insurance has specific rules or regulations, such as the need for referrals, pre-certifications, pre-authorizations and limits on outpatient visits. AGM Physical Therapy is not a party to that contract and is not required to act as a mediator with the carrier or employer. I agree to assume responsibility for any amount not covered by my insurance. I understand and agree that AGM Physical Therapy, or their authorized agents, will be able to contact me electronically and via phone in order to collect balances accrued from services. All balances must be paid within 30 days from the date of invoice. If AGM Physical Therapy must pursue legal action against me to collect any amounts owed by me to AGM Physical Therapy, I agree to pay AGM Physical Therapy’s expenses, including reasonable attorneys’ fees, incurred as a result of legal action.
FINANCIAL RESPONSIBILITY AGREEMENT. I agree to assign insurance benefits to Retina Associates of Kentucky and authorize all insurance payments to be made directly to Retina Associates of Kentucky. I understand that I am financially responsible for all charges whether or not covered by insurance. I acknowledge full financial responsibility for services rendered by Retina Associates of Kentucky and authorize transfer of all unpaid amounts to me, which includes but is not limited to, co-pays, deductibles, co- insurance, excluded conditions and/or termination of coverage. I understand that payment is expected at the time of service. There will be a fee assessed for returned checks.
FINANCIAL RESPONSIBILITY AGREEMENT. All students must complete the financial responsibility agreement process in CedarInfo before they are eligible to reg- ister for Fall Semester 2016. Click on “Financial Responsibility Agreement” under Financial Transactions. Undergraduate and Graduate Students • Confirm your registration date and time through in CedarInfo under “Academic Transactions.” Click on “Class regis- tration date and time.” • Create your schedule plan in Student Planning • Meet with your advisor to discuss your schedule. • Activate your schedule in Student Planning • Verify that your schedule is accurate through CedarInfo under “Academic Transactions.” Click on “View your class schedule, advisor, library ID.” How do I register for online courses? • Instructions for registration for online courses are available on the “Course Schedules” webpage You must come to the Office of the Registrar in SSC-132 to obtain a form to register for: • Classes that are filled • Classes with overlapping meeting times • Classes that require instructor approval • Course overloads • Non-traditional course Registration Schedule Classification is determined by the total hours completed at the time of registration. Credit hours for Spring Semester 2016 courses are not included. Course Information for Fall Semester 2016 is available on the Course Schedules web page located under the “Quick Links” menu on both the current student and faculty and staff homepages. All students, including freshmen, should work with their advisors to develop their class schedules for Fall Semester. Currently-enrolled freshmen will not receive pre-generated schedules for this registration cycle. All current students who plan to continue for Fall Semester 2016 must register for classes and pay the applicable reservation deposit of by May 1st.
FINANCIAL RESPONSIBILITY AGREEMENT. I acknowledge that my program costs must be paid in full on or before the final payment deadline or I will jeopardize my attendance for the program. I also acknowledge that if my program costs are not paid in full by the departure date of my faculty-led program, Texas A&M University-Kingsville will not permit my attendance to the program. (initial) I understand that the payment options available to me, can only cover the costs for the program and does not include the tuition & fees for the academic course associated to my faculty-led study abroad program. (initial) I understand that it is my responsibility to work directly with the Business Office in regards to the tuition & fees associated with my faculty-led program and will need to contact the office once the tuition & fees have posted to my student account to make any payment arrangements before the university’s payment deadlines for that semester. (initial) I understand it is my responsibility to read and sign FORM OISP-105, TAMUK Faculty-Led Program Withdrawal Policy, regarding the policy and procedures if I choose to withdraw from my faculty-led program before the departure date. (initial) I, , affirm that I have read and agree to abide by the policies set forth in this document (Print name) in regards to the faculty-led program to . (Program Location) K Student Signature Date
FINANCIAL RESPONSIBILITY AGREEMENT. As a service agreement, Xx. Xxxxxx Xxxxxx requires all patients to acknowledge and sign this form. Please initial, this indicates that you have read and fully understand the terms of this agreement. I understand, I am fully responsible for the fees and charges for my medical services provided by Xx. Xxxxxx. Your appointment is a special time we are holding for you. I understand, a $20.00 administrative fee will be charged for returned checks. This is in addition to the session fees. I understand, it is my responsibility to inform the office of any change in address, employment and contact information I understand and agree to the following fee schedule for changes and cancellation made inside of the allotted cancel/change time frames: For All Patients: Cancellations or changes for appointments must be made at least 24 (twenty-four) hours before the time of the visit. Otherwise, you will be responsible for full payment of that missed appointment. Signature of Patient or Responsible Party and Date
FINANCIAL RESPONSIBILITY AGREEMENT. I/We hereby authorize Richmond Vein Center to furnish all information regarding my medical history, diagnosis and treatment of myself or my child to an insurance company regarding my claims for benefits. If however, said insurer fails to meet this obligation in whole or in part, or if I am non-insured, agree to be responsible for the fee and cost involved in the treatment of the above named patient. I/We authorize payment of medical benefits to the Richmond Vein Center and further understand that should my account have to be referred to an attorney for collection that I am responsible for all fees and costs incurred therein. I/We hereby authorize Richmond Vein Center to act on my behalf in accessing hospital records when and if needed. Patient/Guardian Signature Date In order for us to provide better communication to your physicians regarding your care, please complete the following:
FINANCIAL RESPONSIBILITY AGREEMENT. This Financial Agreement, signed via the online application, constitutes a binding and valid contract between you and Ascension Christian School. I understand that I am required to pay every week, whether my child attends or not. I understand that I will be charged a fee of $6 for every day that my account is past due. I understand that the ELC hours are from 6:30 a.m. to 6:00 p.m., and I will be charged $1 per child, per minute, per child, for every minute late when picking up my child. After every third occurrence during any calendar year of a late pick-up or late arrival, there will be an additional fee of $25.00 assessed for each late pick-up and/or late arrival from that day forward. I understand that if my account becomes delinquent my child will not be permitted to attend until all fees and late charges are paid. I understand that if my account is more than thirty days (30) overdue, that it may be turned over to a collections agency and that in addition to the unpaid amount I owe, I will also pay ACS’s court costs and legal fees incurred in the collection of debt. If I withdraw my child or children without two weeks of prior notice, I agree to pay the regular fees for the two weeks notwithstanding the fact that my child/children did not attend ELC for that period of time. I understand that my child or children can be absent without payment of tuition. I agree to contact the front office to advise them of planned absences and make them aware of illness that necessitate unplanned absences. I acknowledge that days attributable to absences without tuition do not rollover year to year and are not a credit against any amount that I owe or will owe in the future. I agree to pay a $35 fee for any Non-Sufficient Funds (NSF) check written to ACS. I understand that the registration fees, tuition, and activity fees are nonrefundable. By signing this Financial Agreement Form, the signee(s) understands the policies of the Early Learning Center and agrees to abide by all school policies, financial obligations and the refund policies. Effective as of the time of enrollment/re-enrollment, you acknowledge full responsibility for all obligations, including but not limited to your financial obligations. Mother/Father’s Signature: Date:
FINANCIAL RESPONSIBILITY AGREEMENT. I understand that charges not covered by my Insurance or by my secondary insurance if applicable are my responsibility if applicable as well as deductible, coinsurance, copayments are my responsibility. All professional services are charged to the patient at the time of service unless other arrangements are made unless other arrangements are made by the patient or his or health insurance carrier. If your insurance company has not paid the account in 90 days balance may be transferred to you (patient) for the payment. If your insurance is HMO or other managed care, Xxxx X Xxxx MD PA, will only bill them if you provide appropriate authorization form from them. You may still be responsible for deductibles, copayments and non-covered services. If you don’t have an appropriate authorization for each visit/ treatment/ procedure you may be responsible for the entire payment. For companies with whom our Physicians don’t participate payment for the visit will be your responsibility, XXXX X XXXX MD PA will bill your carrier after the second visit. I understand that if I default on payments for services my account may be transferred to an independent collection agency designated as credit risk and payment for services will be requires at the time of registration for all future visits. I have read the financial policy as above and I understand and agree to it. Initial: MISSING APPOINTMENTS Your appointment time is set aside especially for you. Resources are assigned to each individual patient. We ask that for the courtesy of the patient and the doctor, you show up to your scheduled appointment on time. If you do not show up to your scheduled appointment on time, there may be a charge of $50. Initial:
