FINANCIAL POLICY AGREEMENTFinancial Policy Agreement • October 25th, 2021
Thank you for choosing REHABVISIONS. We look forward to serving you. If you ever have any questions or concerns, please bring them to our attention.
FINANCIAL POLICY AGREEMENTFinancial Policy Agreement • May 1st, 2023
This policy will be administered by the office staff of St. Anthony School, with guidance from the School Principal and Pastor of St. Anthony Catholic Church. The effectiveness of this Policy will be reviewed on a regular basis by St. Anthony School Commission and Finance Committee.
FINANCIAL POLICY AGREEMENTFinancial Policy Agreement • April 22nd, 2022
Thank you for choosing Precision Dental as your dental provider. Your clear understanding of our Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, Financial Policy, or your responsibility.
FINANCIAL POLICY AGREEMENTFinancial Policy Agreement • December 20th, 2018
FINANCIAL POLICY AGREEMENTFinancial Policy Agreement • February 13th, 2019
For Our Patients with Medical Insurance Benefits: Endocrinology of Central Pennsylvania (the “Practice”) participates in most major health plans and has contracts with many HMOs, PPOs, and government insurers including Medicare and Tricare. The Practice’s business office submits claims to your plan for covered services rendered to you as a patient of the Practice and will assist you in any way the Practice reasonably can to help get your claims paid. It is the patient’s responsibility to provide all necessary information as requested by the Practice. If you have a secondary insurance, the Practice will automatically file a claim with them as soon as the primary carrier has paid. Your insurnce company may need you to supply certain information directly. It is your responsibility to comply with their request.
Patient Financial Policy AgreementFinancial Policy Agreement • June 10th, 2016
Thank you for choosing the Spine Institute of Central Florida as your health care provider. We are committed to providing you with the best possible care. Payment of your bill is considered a part of our professional relationship and a clear understanding of our financial policy is important.
FINANCIAL POLICY AGREEMENTFinancial Policy Agreement • March 1st, 2017
Financial Policy AgreementFinancial Policy Agreement • March 2nd, 2021
Welcome to Dr. Jenny Wang’s dental office where we are dedicated to serve as your oral health care provider. This Financial Policy Agreement is intended to respect your right to know what to expect, financially, for your treatment, and to maximize our ability to provide excellent service.
FINANCIAL POLICY AGREEMENTFinancial Policy Agreement • July 29th, 2021
Thank you for choosing us as your dental health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our Financial Policy Agreement which we require that you read and sign prior to your treatment.
Financial Policy AgreementFinancial Policy Agreement • July 22nd, 2024
Signing a new agreement today at any Nao Medical/HFMC location supersedes patient agreements that Nao Medical/HFMC may have on file.
FINANCIAL POLICY AGREEMENTFinancial Policy Agreement • January 20th, 2020
Individual insurance policies have varied coverage for things like frequency of preventive visits or physicals, non-preventive services, blood work or labs, travel vaccinations, etc. While we make every available effort to assist you, understanding the details of your coverage is your responsibility.
FINANCIAL POLICY AGREEMENTFinancial Policy Agreement • October 25th, 2021
Thank you for choosing REHABVISIONS. We look forward to serving you. If you ever have any questions or concerns, please bring them to our attention.
Insurance & Financial Policy AgreementFinancial Policy Agreement • June 27th, 2024
● Knowledge of your insurance benefits is your responsibility. If you have changes to your insurance, please inform the front desk staff prior to or upon arrival to your appointment.
Financial Policy AgreementFinancial Policy Agreement • April 21st, 2015
Thank you for choosing us for your dental needs. We are committed to providing you with excellent care, and convenient financial arrangements are a part of successful, predictable treatment results. Our financial arrangements are based on an open and honest discussion of recommended treatment options, respective fees and our patients’ financial capabilities. Please read, sign, and return the following:
Financial Policy AgreementFinancial Policy Agreement • September 16th, 2019
The ENT Center is committed to providing the best possible care for our patients. All paperwork must be filled out prior to seeing the physician. We will need to scan or photocopy your insurance card(s) and your photo identification when you check in for your appointment. Your clear understanding of our Financial Policy Agreement is important to our professional relationship. Please let us know if you have any questions regarding our fees or your financial responsibility.
FINANCIAL POLICY AGREEMENTFinancial Policy Agreement • March 25th, 2024
Our mission is to deliver the finest most cost effective Dental Care available today. Following diagnosis, the Dentist will advise you on a plan for treatment (Treatment Plan). Additionally, we will discuss with you the cost of today’s visit and any future treatment.
Financial Policy Agreement (FPA)Financial Policy Agreement • August 18th, 2015
Thank you for choosing Parkway Family Eye Clinic, Inc. (PFEC) to treat your eye care needs. We are committed to excellent patient care. Below we have provided an explanation of our Financial Policy Agreement (FPA). Patients must complete the FPA prior to receiving services.
Financial Policy AgreementFinancial Policy Agreement • May 31st, 2021
It is the goal of Modern Eyecare to have a financial policy that clearly outlines the patient’s and the practice’s financial responsibilities. This financial policy has been established to avoid any misunderstanding or disagreement concerning payment for professional services.
FINANCIAL POLICY AGREEMENTFinancial Policy Agreement • November 18th, 2020
Treatment plans are based upon an estimated calculation. It may be necessary to do additional treatments, which will result in a change of fees and the amount you owe.
FINANCIAL POLICY AGREEMENTFinancial Policy Agreement • July 7th, 2014
This is an agreement between Complete Care Center and the Patient named on this form. In this agreement the words “you,” “your,” and “yours” mean the Patient. 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 Complete Care Center. By executing this agreement, you are agreeing to pay for all services that are received.
PIONEERS MEDICAL CENTER/MEEKER FAMILY HEALTH CENTER FINANCIAL POLICY AGREEMENTFinancial Policy Agreement • September 2nd, 2020
Thank you for choosing Pioneers Medical Center/Meeker Family Health Center for your healthcare needs. It is our commitment to provide quality medical care to our patients. This financial policy is a general outline of your financial responsibilities to Pioneers Medical Center/Meeker Family Health Center.
Financial Policy AgreementFinancial Policy Agreement • September 15th, 2020
Thank you for choosing Rosedale Health & Wellness for your healthcare needs. We are dedicated to providing you with quality up to date personal care. In consideration of receiving services from Rosedale Health & Wellness, your agreement with our financial policy is required.
NEW PERSPECTIVES HEALTH CARE, LLCFinancial Policy Agreement • May 28th, 2021
Financial Policy AgreementFinancial Policy Agreement • November 15th, 2022
We strive to deliver the finest care possible at a reasonable cost to our patients. Thank you for your trust and confidence in us, because we value you as a patient, we want to ensure that you have a clear understanding of our payment policy.
Financial Policy Agreement Self-Pay / Health Insurance CoverageFinancial Policy Agreement • August 8th, 2016
This method of billing designed by the insurance industry, forces us to bill at full price procedure codes that the insurance company will likely reduce, combine, or simply deny. This system in fact, has the insurance company determining our fees. If we have a contract with your insurance company, we write-off the amount over the “reasonable and customary”, and bill you for your coinsurance and deductible. If we do not have a contract with your insurance carrier, you are responsible for that amount as well as any deductible and coinsurance.
FINANCIAL POLICY AGREEMENTFinancial Policy Agreement • March 8th, 2019
To reduce confusion or misunderstanding we ask that you read this Financial Policy Agreement, ask any questions, and sign the Authorization and Acknowledgement. Other than for true medical emergencies, agreement with this policy is required for all medical care. We appreciate your commitment to adhere to this Financial Policy Agreement.
FINANCIAL POLICY & AGREEMENTFinancial Policy & Agreement • September 12th, 2024
It is our goal to provide you and your family with the highest quality dental care. We are committed to supporting you in understanding your dental health, and will present you with the best dental solutions available. We hope that this Financial Agreement will facilitate open communication between us, allowing you to make the best choices related to your care and help avoid potential misunderstandings. We are always available to answer your questions or assist you in any way we can.
Financial Policy AgreementFinancial Policy Agreement • September 11th, 2021
Thank you for choosing us for your dental needs. We are committed to providing you with excellent care, and convenient financial arrangements are a part of successful, predictable treatment results. Our financial arrangements are based on an open and honest discussion of recommended treatment options, respective fees and our patients’ financial capabilities. Please read, sign, and return the following:
Scott A. Fleischer, M.D., P.C., & AssociatesFinancial Policy Agreement • February 5th, 2021
Welcome to Dr. Fleischer’s office. Enclosed you will find the necessary forms that need to be completed prior to your first appointment with our office. Please complete any highlighted areas and return them to our office.
FINANCIAL POLICY AGREEMENTFinancial Policy Agreement • March 5th, 2019
We would like to thank you for choosing NewYork-Presbyterian / Weill Cornell Medicine Integrative Health and Wellbeing as your healthcare provider. We consider it an honor and privilege to participate in your care.
Financial Policy AgreementFinancial Policy Agreement • May 7th, 2020
We strive to deliver the finest care possible at a reasonable cost to our patients. Thank you for your trust and confidence in us, because we value you as a patient, we want to ensure that you have a clear understanding of our payment policy.
FINANCIAL POLICY AGREEMENTFinancial Policy Agreement • October 25th, 2021
Thank you for choosing DUMAS PHYSICAL THERAPY. We look forward to serving you. If you ever have any questions or concerns, please bring them to our attention.
Financial Policy AgreementFinancial Policy Agreement • December 30th, 2021
• We are happy to accept hundreds of other dental insurance plans on an out-of-network basis. We will work with your carrier to maximize your benefits and directly bill them for reimbursement. If we do not receive payment from your insurance carrier within 60 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier.
FINANCIAL POLICY AGREEMENTFinancial Policy Agreement • November 3rd, 2023
Thank you for choosing REHABVISIONS PHYSICAL THERAPY. We look forward to serving you. If you ever have any questions or concerns, please bring them to our attention.
FINANCIAL POLICY AGREEMENTFinancial Policy Agreement • April 27th, 2021
INSURANCE BILLING: Please make sure to provide us with your current healthcare insurance policy information and healthcare insurance card. If you have more than one insurance company, please provide information on all policies and advise us which payer is primary. We will bill primary and secondary insurance companies, and you will receive statement for any remaining balance after we receive payment from your insurance.
