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.
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.
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.
Financial PolicyFinancial Policy • January 2nd, 2019
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 • 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.
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
Financial PolicyFinancial Policy • November 16th, 2023
Your Health is our first and foremost Priority. Dental care will always be rendered based on need and no other factor will affect the quality of that care.
FINANCIAL POLICYFinancial Policy • November 15th, 2017
This is an agreement between Woodland Family Dental and , the patient. By executing this agreement, you are agreeing to pay for all services that are received.
Financial PolicyFinancial Policy • May 4th, 2016
In this agreement, this agreement, the words “you”, “your”, and “yours” means 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” and “our” refer to Dr. Vivian Fraga, LLC.
Financial PolicyFinancial Policy • June 23rd, 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 1.5% fee on ALL credit and debit cards effective December 16, 2020. Returned checks will be assessed a $30 fee.
This is an agreement between Northeast Pain Management, P.C., as creditor, and the Patient/Debtor named on this form.Financial Policy • February 22nd, 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 Northeast Pain Management, P.C.
Financial PolicyFinancial Policy • May 29th, 2023
This is an agreement between Third Creek Dentistry and the Patient named on this form. By executing this agreement, you are agreeing to pay for all services that are received.
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.
