Financial PolicyFinancial Policy • September 8th, 2021
In this agreement, the words “you”, “your” and “yours” mean the Patient/Debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words “we”, “us”, and “our” refer to Dr.
By executing this agreement, you are agreeing to pay for all services that are receivedFinancial Policy • January 26th, 2022
issued, and is past due if not paid within 30 days of statement date. Other arrangements may be made but must be approved by us in writing. Please contact us for billing questions at 919-615-0018.
FINANCIAL POLICYFinancial Policy • August 15th, 2017
Your signature below forms a binding agreement between Spring Hill Dermatology, PLC (provider of medical services) and the Patient who is receiving medical services, or the Responsible Party for minor patients (those under 18 years old). Responsible Party is the individual who is financially responsible for payment of medical bills.
Financial PolicyFinancial Policy • June 26th, 2023
Financial PolicyFinancial Policy • August 4th, 2021
Acre Wood Dental Financial PolicyFinancial Policy • April 12th, 2023
Thank you for choosing us to provide your dental care. We consider it an honor to have been chosen by you to do so. Our philosophy in serving people is to be informative, honest and forthright. Nowhere is that more important than in the area of finances. This Financial Agreement is indicative of our respect for your right to know ahead of time what our expectations are in the area of finances. If you have any questions or concerns about our Financial Agreement please do not hesitate to ask our business office staff.
Financial PolicyFinancial Policy • September 13th, 2019
Terms: This is an agreement between Gunderson Eyecare, P.C., as creditor, and the Patient/and Responsible Party named on this form, as debtor. In this agreement the words “you, your, and yours” mean the Patient/and Responsible Party. The word “account” means the account that has been established in patients or responsible party’s name to which charges are made and payments credited. The words “we, us, and our” refer to Gunderson Eyecare, P.C. By executing this agreement, you are agreeing to pay for all services that are received.
Westport Pediatric Dentistry Financial PolicyFinancial Policy • February 4th, 2021
- After your insurance pays or denies your claim, we will charge your credit card on file the remaining balance on your account and e-mail you a receipt same-day.
This is an agreement between San Marcos Orthopedics and the Patient/Debtor named on this form.Financial Policy • February 19th, 2024
You can choose to pay your deductible, coinsurance, and/or copayments by CASH, CHECK, or CREDIT CARD. Any copayments must be collected before seeing the physician.
This is an agreement between the doctors of Capital Vision Center PC, and the Patient/Debtor named on the form.Financial Policy • March 1st, 2012
In this agreement the words “you,” “your,” and “yours” mean the Patient/Debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words “we,” “us,” and “our” refer to the doctors of Capital Vision Center PC.
FINANCIAL POLICYFinancial Policy • June 7th, 2022
We are committed to providing our patients with the best dental care possible. Included in that commitment is an open dialogue of our fees and financial policies. This agreement provides a written statement of our policies and procedures. Please review the following information. If you have any questions, please discuss this information with the doctor or his representative.
Financial PolicyFinancial Policy • May 16th, 2021
q You choose to pay by cash, check, debit, or credit card on the day that treatment is rendered. Please note there is a 3.5% fee on credit cards (excluding HSA, debit cards, and Flex Cards) effective October 26, 2020. Returned checks will be assessed a $30 fee.
Scott W. Berneburg, DPM, Inc. (dba Beckley Foot & Ankle Clinic)Financial Policy • August 6th, 2018
This is an agreement between Scott W. Berneburg, DPM, Inc. (dba Beckley Foot & Ankle Clinic) and the Patient/Responsible Party named on this form. By executing this agreement, you are agreeing to pay for all services that are received.
PRP DentalFinancial Policy • October 4th, 2021
This agreement is to inform you of your financial obligation to our practice. We are committed to providing you with the highest quality dental care using only the best material and technology available In the market today. We are also committed to providing you with up-to-date information and educational tools so that you may fully participate in maintaining optimum oral health.
ContractFinancial Policy • November 15th, 2017
This financial agreement is intended to facilitate our ability to provide excellent service while informing you of your financial obligation to our practice.
Dental insurance is a contract between the subscriber and the insurance company. In order to keep our fees as low as possible, payment is due prior to services rendered. In some cases we may ask that you prepay for dental services to reserve special...Financial Policy • March 5th, 2021
_____ Tooth Squad Dentistry will gladly file to your insurance via electronic submission as a courtesy to you. It is your responsibility to provide our office with all the necessary insurance information prior to the appointment time and be familiar with your insurance coverage. Notification is required when dental insurance coverage or address/contact phone numbers have changed. If applicable, we will also to file secondary insurance as well.
FINANCIAL POLICYFinancial Policy • August 12th, 2020
Your Signature below forms a binding agreement between Spring Hill Dermatology, PLC (provider of medical services) and the Patient who is receiving medical services, or the Responsible Party for minor patients (those under 18 years old).
MONTGOMERY VASCULAR SURGERY, P.C.Financial Policy • February 12th, 2021
Thank you for choosing Montgomery Vascular Surgery for your medical care. Please understand that our service agreement is with YOU and NOT your insurance company. Just as you have chosen your insurance coverage, you are responsible for payment for the service(s) rendered and claims are filed as a courtesy by our office.
AGREEMENT FOR PAYMENT FOR SERVICES:Financial Policy • April 10th, 2014
Full Payment for services are due at the time of service, and collected at the beginning of each appointment. Any insurance co-payments are due at time of service. You must provide your insurance card and identification-at-each visit, which is subject for verification prior to your appointment time. CBHS reserves the right to cancel your appointment if proof of insurance cannot be verified or is not provided or require full visit fee be paid prior to your appointment.
Financial Agreement: Patients are expected to pay for our services at the time services are rendered. Our patients who have dental insurance are expected to pay the amount of their estimated copay and deductible. We accept cash/check/Visa/Master cards.Financial Policy • June 2nd, 2020
Appointments: In order to serve you better and keep the cost of dental care down, we try to maintain an efficient appointment system. However, our cost of providing care increases greatly when people fail to keep scheduled appointments or cancel at the last minutes.
This is an agreement between Shayegan Shamsaie, D.D.S., as creditor, and the Patient/Debtor named on this form.Financial Policy • February 6th, 2014
In this agreement the words "you," "your," and "yours" mean the Patient/Debtor. The word "account" means the account that has been established in your name to which charges are made and payments credited. The words "we," "us," and "our" refer to Shayegan Shamsaie, D.D.S.
Financial PolicyFinancial Policy • March 9th, 2017
Thank you for choosing Neu Family Dental as your dental health care provider. Our goal is to provide you and your family with optimal dental care. We want you to feel welcome and as comfortable as possible throughout our relationship. We encourage you to ask questions and to be highly involved in treatment decisions. This includes understanding your treatment plan as well as our financial policy.
This is an agreement between Otolaryngology Associates, as creditor, and the Patient/Debtor named on this form.Financial Policy • June 21st, 2010
Payment Options: All previous balances are due at the time of service unless previous arrangements have been made with our Business Office. You may pay your out-of-pocket costs at the time of service by check, cash or credit card. Failure to make appropriate copayments at the time of service may result in a service charge of $10. If you are unable to pay your full out-of-pocket costs at the time of service, you may make payment arrangements through our Business Office by calling 703-573-5979. These options include a payment plan not to exceed three months on amounts less than $250.00 and six months on amounts over $250.00. Automatic payments can be arranged via credit card.
Financial PolicyFinancial Policy • October 9th, 2010
patient/Debtor named on this form. In this agreement the words “you”, “your”, and “yours” mean the Patient/Debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words, “we”, “us”, and “our” refer to TLC Pediatrics of Amarillo, P.A. By executing this agreement, you are agreeing to pay for all services that are received.
This is an agreement between the office of Aaron C. Polk, D.D.S. Dentistry and the Patient/Debtor named on this form.Financial Policy • November 19th, 2020
In this agreement, the words “you,” “your,” and “yours” mean the Patient/Debtor. The word “account” means the account that has been established in your name to which charges are made and payments are credited. The words “we,” “us,” and “our” refers to the office of Aaron C. Polk, D.D.S. Dentistry. By executing this agreement, you are agreeing to pay for all services that are received.
Financial Policy This is an agreement between Dentistry by Design, located in Minnetonka Minnesota, and the Patient named on this form. By executing this agreement, you are agreeing to pay for all services that are received.Financial Policy • March 6th, 2018
Insurance: Insurance is a contract between you and your insurance company. We are NOT party to this contract. We will bill your primary insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility. You agree to pay any portion of the charges for services rendered but not covered by your plan or not paid (denied) by your insurance. You must inform us if you lose or are about to lose your insurance coverage. Any services rendered after insurance eligibility terminates will be charged at our standard fees. By signing below, you give Dentistry by Design the permission to release any information needed to your insurance agency or respective healthcare provider and assign the insurance benefits over to your dental clinic: Dentistry by Design, Atif H. Rizvi, DDS. The above-named doctor and facility may use your healthcare information and may disclose such information to
Financial PolicyFinancial Policy • May 12th, 2020
This agreement is to inform you of your financial obligation to our practice. We are committed to providing you with the most comprehensive dental care, using only the highest quality materials and technology available in the market today. All charges you incur for any provided treatment are your responsibility, regardless of your insurance coverage. We will always recommend treatment based upon your dental needs, not based on insurance coverage, which can be inadequate with some dental plans. Dental insurance is a benefit used to assist you, not to dictate necessary treatment.
Craig L. Meadows, DDS, PLLCFinancial Policy • June 3rd, 2015
In this agreement the words “you”, “your”, and “yours” mean the Patient/Debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words “we”, “us” and “our” refer to Craig L. Meadows, DDS.
Dustin V. Goodwin, DDS, PCFinancial Policy • May 30th, 2018
We are committed to providing you with the highest quality of dental care. In doing so, we have created a financial policy to reduce our administrative costs and keep our fees as low as possible. By signing below, you agree to the following:
FINANCIAL POLICYFinancial Policy • April 11th, 2019
This agreement is to inform you of your financial obligation to our practice. We are committed to providing you with the most comprehensive dental care using only the highest quality material and technology available in the market today. We are also committed to providing you with up-to-date information and educational tools so that you may fully participate in maintaining optimum oral health. This financial agreement is intended to facilitate our ability to provide excellent service to you while minimizing our costs to you.
Lafayette General Endoscopy Center ● Financial PolicyFinancial Policy • October 28th, 2014
Thank you for choosing Lafayette General Endoscopy Center for your Endoscopy Procedures. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is our Financial Policy & Agreement that we require you to read and sign before any treatment.
FINANCIAL POLICYFinancial Policy • September 1st, 2021
This is an agreement between A Plus Urgent Care a California Corporation as creditor, and the Patient/Debtor named on this form. In this agreement the words “you”, “your”, and “yours” mean the Patient/Debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words “we”, “us”’ and “our” refer to A Plus Urgent Care.
FOLAN FAMILY DENTAL FINANCIAL POLICYFinancial Policy • August 20th, 2021
Thank you for choosing Folan Family Dental as your dental care provider. At Folan Family Dental, we are committed to providing you with the highest quality dental care, using only the best material and technology available. We are also committed to providing you with up-to-date information and educational tools so that you may fully participate in maintaining optimum oral health. This financial agreement is intended to facilitate our ability to provide excellent service to you while minimizing our administrative costs.
ADVANCED HEARING SERVICES, INC. FINANCIAL POLICYFinancial Policy • October 22nd, 2020
This is an agreement between the Advanced Hearing Services, Inc., an affiliate of Otolaryngology Associates, as creditor, and the Patient/Debtor named on this form.
FINANCIAL POLICYFinancial Policy • April 24th, 2009
This is an agreement between Kurt Vernon MD PA a North Carolina Professional Corporation, as creditor, and the Patient/Debtor named on this form. In this agreement the words “you, your, and yours” mean the patient/Debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words "we," "us," and "our" refer to Kurt
