AGREEMENT TO PAY ---------------- BLUE CROSS AND BLUE SHIELD OF MINNESOTA --------------------------------------- ATTORNEYS' FEES AND COSTS -------------------------Agreement to Pay • May 15th, 1998 • Loews Corp • Fire, marine & casualty insurance • Minnesota
COUNTY OF NEVADA COMMUNITY DEVELOPMENT AGENCYAgreement to Pay • April 3rd, 2013
AGREEMENT TO PAYAgreement to Pay • July 30th, 2009
Thank you for choosing the Columbus Speech & Hearing Center as your provider of services. We are a nonprofit organization that has been serving Central Ohio since 1923. Fees are charged for the professional services rendered to the patient. The patient/responsible party does accept complete responsibility for payment.
AGREEMENT TO PAY 2021 MATERIALS & SERVICES CHARGES BY INSTALMENTSAgreement to Pay • December 15th, 2020
I/We agree that I/we am/are indebted to Hendon Primary School Governing Council Incorporated (“the school”) for the sum of $ and that I/we will pay this sum in accordance with the following terms:
Agreement to PayAgreement to Pay • December 20th, 2017
NAME: CASE NUMBER: ADDRESS: APT/LOT#: CITY, STATE: ZIP CODE: JUDGE/DIVISION: DATE OF BIRTH: EMPLOYER: ADDRESS:PHONE NUMBER: SOCIAL SECURITY NUMBER: TELEPHONE NUMBER: CELL PHONE NUMBER: E-MAIL ADDRESS: REFERENCE NAME / TELEPHONE NUMBER: I acknowledge that I currently owe the Court the amount of $ . I understand the costs and fine are due within 90 days of the sentencing date. In 30 days $25 will be added to any court costs or fine not paid in full. In 90 days the Court will be notified if the fine is not paid in full. I understand that I have been ordered to pay court cost and fine. Failure to pay as required may result in:1. A warrant for my arrest.2. A requirement to appear in court.3. Delinquent amounts being turned to tax intercept.4. Delinquent amounts being turned over to a collection agency which will add an additional percentage to the amount owed.5. Credit agency reporting.6. Revocation of drivers’7. Revocation of probation if payment is a condition of probation.I understand th
ContractAgreement to Pay • February 13th, 2013
AGREEMENT TO PAY Where the tests requested are related to care provided by a public hospital, the charge will be directed to the relevant hospital. An Agreement to Pay form is not required and the patient will not receive an invoice for these tests. Patient DetailsName DOB / / Address Postcode Email Mobile number Referring PractitionerName Provider No. Address Postcode Tests Requested Test Name Price (ex GST) Total Person/Institution Responsible for Payment Name Address Po stcode I understand that the test requested is not covered by Medicare. I have been advised understand that I will receive an invoice from SA Pathology for this service, and I acce the full payment of the fee for the test. of the cost andpt responsibility for Date / / Signature An Agreement to Pay form is required in the following circumstances:• When the test requested is not covered by the Medicare Benefits Schedule (MBS• When the test requested is ‘sent away’ to an external tes
AUTAUGA STATION DENTAL 1803 STATION DRIVE SUITE, A PRATTVILLE, AL 36066Agreement to Pay • December 7th, 2009
AGREEMENT TO PAYAgreement to Pay • June 22nd, 2018
Agreement to PayAgreement to Pay • March 25th, 2020
By signing below I agree to pay for services I receive at Family Service of the Piedmont (including individual, couples, group and family therapy, and court appearances) according to the fee schedule or the per visit co-pay listed below. I agree that it is my responsibility to notify Family Service of the Piedmont of any change that may affect my payment. This may include, but is not limited to, change in income, change in insurance coverage, Medicaid or Medicare eligibility status, family size or other change that might affect my eligibility for benefits. Failure to notify Family Service of the Piedmont of such change may result in my being liable for 100% of fees for services provided by Family Service of the Piedmont.
ContractAgreement to Pay • February 26th, 2009
AGREEMENT TO PAY (Read and Sign by Person Responsible for Payment)Agreement to Pay • March 18th, 2015
Agreement to PayAgreement to Pay • January 22nd, 2013
Printing color figures in Child Development requires a payment of $325 per figure. When your article publishes in the print issue, you will be invoiced the total charges on this form.
AGREEMENT TO PAY 2020 MATERIALS & SERVICES CHARGES BY INSTALMENTSAgreement to Pay • March 12th, 2020
I/We agree that I/we am/are indebted to Hendon Primary School Governing Council Incorporated (“the school”) for the sum of $ and that I/we will pay this sum in accordance with the following terms:
ContractAgreement to Pay • February 26th, 2009
