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 • October 8th, 2024
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.
ContractFinancial Policy Agreement • July 6th, 2022
At Dermatology San Antonio, we believe that all patients who are rendered care at this office deserve the best medical care that can be provided. We provide you with the Agreement regarding our financial policy and your agreement to pay for services provided so that you are aware of our policies and procedures up front. We require each patient to sign and date this Agreement on the last page to indicate you accept these terms.
FINANCIAL POLICYFinancial Policy Agreement • January 17th, 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
Financial Policy AgreementFinancial Policy Agreement • October 10th, 2018
Thank you for choosing Pain & Neurology Specialists of Beaufort, P.A. for your health care needs. Our primary concern is that you receive the most appropriate treatment to restore and maintain your good health; as with any type of medical care, understanding the financial impact and responsibilities associated with that treatment is also important. It is important that you read this financial policy agreement before receiving treatment.
Financial Policy Agreement License capacity Hours of OperationFinancial Policy Agreement • February 6th, 2022
Peachtree Family Day Care is open from 8:00 AM until 6:00 PM Monday through Friday. Hours of care will be contracted from child to child.
Notice of Financial PolicyFinancial Policy Agreement • January 16th, 2021
FINANCIAL POLICY AGREEMENT 2023 – 2024Financial Policy Agreement • February 18th, 2021
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.
BLOOMFIELD FOOT SPECIALISTS, LLC 1 NORTHWESTERN DRIVE, SUITE 301Financial Policy Agreement • September 7th, 2022
All co-pays and past due balances are due and payable at the time of service unless prior arrangements have been made. Your insurance company requires us to collect your co-pay at the time of your visit. It is not our policy to bill you for your co-pay; if not paid at the time of service a $10 fee will be assessed. Payment may be made with cash, check, Visa or MasterCard. We do not take Discover or American Express.
FINANCIAL POLICY AGREEMENTFinancial Policy Agreement • December 20th, 2018
Financial Policy AgreementFinancial Policy Agreement • July 15th, 2024
Payment for services provided by Phoenix Pointe Psychiatry LLC, hereafter may be referred to as “PPP”, is due at the time that services are rendered. If the patient is covered under insurance, payment of any applicable co-payment, co-insurance, or deductible is due at the time of service. If Phoenix Pointe Psychiatry is not contracted with the insurance, payment for services is due in full at the time that services are rendered through accepted forms of payment by the facility. Insurance will be billed on your behalf and you will be reimbursed any applicable credits. Phoenix Pointe Psychiatry makes every effort to verify your coverage with your insurance, however, you are strongly encouraged to verify your benefits and coverage to ensure you fully understand what is covered. You agree that it is your responsibility to inform the practice of any changes to the insurance plan prior to each of your visits, or you may be responsible for the full fee. Some services may not be covered by hea
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.
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.
Advanced Foot Care Center, LLC Financial Policy AgreementFinancial Policy Agreement • September 21st, 2020
We are pleased that you have chosen our office to help you with your healthcare needs. The doctors and staff of Advanced Foot Care Center, LLC strive to provide you with the best, up to date treatments possible. It is our goal to provide you an excellent experience prior, during and after you have been treated by our office. We ask that you review the policy agreement below, so that you understand your financial obligations.
RAMOUNA KARVAR, D.M.D.Financial Policy Agreement • May 20th, 2015
- No interest or low interest payment financing options may be available through a third party, CareCredit. Please speak with our office manager if interested in applying.
Print, complete and bring to appointmentFinancial Policy Agreement • February 6th, 2010
Purpose: This is an agreement between the St. Petersburg Dental Center, and the named patient and responsible party on this form. We appreciate you choosing us for your dental needs and we want to be sure you fully understand your financial obligations for the services we will be providing. By signing this agreement, you are agreeing to Pay for all services rendered.
Financial PolicyFinancial Policy Agreement • September 11th, 2021
This is an agreement between Dr. Kurt Barth, as creditor, and the Patient / Debtor on this form. I this agreement, the words you, your, and yours mean the patient / Debtor.
ContractFinancial Policy Agreement • October 27th, 2016
Agreement Regarding Insurance, Benefits and PaymentFinancial Policy Agreement • March 19th, 2021
We believe that part of good healthcare practice is to establish and communicate a financial policy to our patients. For that reason, we have set forth our financial policy below.
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 • October 11th, 2018
Thank you for choosing Neurology Specialists of Charleston, P.A. for your health care needs. Our primary concern is that you receive the most appropriate treatment to restore and maintain your good health; as with any type of medical care, understanding the financial impact and responsibilities associated with that treatment is also important. It is important that you read this financial policy agreement before receiving treatment.
FINANCIAL POLICY AGREEMENT 2021 – 2022Financial Policy Agreement • February 18th, 2021
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.
ContractFinancial Policy Agreement • October 4th, 2023
ContractFinancial Policy Agreement • December 5th, 2018
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.
OFFICE ⁄ FINANCIAL POLICY AGREEMENTFinancial Policy Agreement • July 26th, 2018
Thank you for choosing TMS Solutions for your TMS medical care. We are committed to providing you with quality, personal health care, and appreciate your commitment to adhere to this Office ⁄ Financial Policy Agreement. By understanding our policy, we can provide you with the best service. Agreement with this policy is required for all medical care.
FINANCIAL POLICY AGREEMENT 202ϰ – 202ϱFinancial Policy Agreement • February 18th, 2021
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.
