Common Contracts
1 similar Patient Service Agreement contracts
PATIENT SERVICE AGREEMENTPatient Service Agreement • August 29th, 2016
Fees: Our fees for services are billed on a biweekly basis. You will receive a monthly statement that will contain a complete itemization of charges and will reflect payments to date. All charges are due and payable on due date of receipt. A finance charge of 1.5% per month (18% annually) will accrue on accounts 60 days or older. All patient co-pays are due at the time of service. If patient applies to Medical Assistance (MA) and is approved, all monies paid between the retroactive effective date and approval date will not be reimbursed, and MA will not be billed for those services. A $25.00 service fee will be assessed for all NSF/insufficient fund checks.
