Financial Policy and AgreementFinancial Policy and Agreement • July 27th, 2015
Thank you for choosing us as your healthcare provider. We are committed to providing you with the best possible medical care. Please understand that payment of your bill is considered a part of your treatment. The following is provided to avoid any misunderstanding or disagreement concerning payment for services, tests, and supplies provided by our office.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • March 12th, 2023
Definitions. In this Agreement, “Office” and “Clinic” shall refer to THE PHYSICAL THERAPY CLINIC, INC. dba AXIS PHYSICAL THERAPY located at 26 Office Park Dr. Jacksonville, NC 28546. “Financial Policy” or “Agreement” shall refer to this document.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • September 16th, 2011
Financial Policy and AgreementFinancial Policy and Agreement • December 29th, 2020
Thank you for choosing Amaryllis Therapy Network. We look forward to working with you and your child to meet your child’s therapeutic needs. In that effort, we have developed a financial responsibility policy to avoid any misunderstanding and to ensure timely payment for therapy services. Our practice firmly believes in honesty and transparency. If you have any questions, please call our office at 303.433.0852.
LEGACY DENTAL GROUP FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • January 20th, 2014
We realize that every person’s financial situation is different. For this reason we have worked hard to provide a variety of payment options to help you receive the dental care needed to enjoy a healthy and confident smile while respecting to your budget. With regards to dental insurance or benefits, we are happy to file the forms necessary to see that you receive the full benefits of your coverage; however we can make no guarantee of any estimated coverage. Because the insurance policy is an agreement between you and the insurance company, we ask that all patients be directly responsible for all charges. Please know that we will do everything possible to see that you receive the full benefits of your policy. If for some reason your insurance company has not paid the estimated portion within 30 days from the date of treatment, you are responsible for payment at that time. Please present your insurance card at each visit. To better serve you, all insurance information must be provided a
FINANCIAL POLICY and AGREEMENTFinancial Policy and Agreement • November 28th, 2022
We value our patients and are committed to the highest quality of care from our Doctor and Staff. We are happy to discuss our fees or office financial policy at any time.
FINANCIAL POLICY AND AGREEMENT FOR SEEBERGER DERMATOLOGY, LLCFinancial Policy and Agreement • March 21st, 2023
Thank you for choosing us as your healthcare provider. We are committed to providing you with the best possible medical care. Your clear understanding of our practice financial policy is important to our professional relationship. The following information outlines your responsibility related to payment and appointment reservation for professional services. In order to keep healthcare costs to an absolute minimum, we have adopted the following policies.
FINANCIAL POLICY and AGREEMENTFinancial Policy and Agreement • November 29th, 2022
We are pleased and honored that you have selected Spring Creek Dental for your dental needs. Our team is fully committed to delivering the absolute highest quality dental care available and providing you with the tools to maintain your investment in yourself for years to come.
Bailey Dental Financial Policy and AgreementFinancial Policy and Agreement • September 29th, 2013
Thank you for choosing Bailey Dental for your dental needs. We are dedicated to providing you with exceptional care and convenient financial arrangements. Our financial arrangements are based on an open and honest discussion of recommended treatment options, respective fees and our patients’ financial capabilities.
SUMMIT EYECARE Insurance and Financial Policy and Financial Policy and AgreementFinancial Policy and Agreement • October 27th, 2023
Thank you for choosing Summit Eyecare as your provider. The following is our Financial Policy and Agreement and Notice of Privacy Practices. Please read, initial, and sign prior to being evaluated by one of our providers.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • June 17th, 2014
Thank you for choosing Canyon Golf Family Dentistry. In an effort to better serve you, we would like to take the time to explain the financial policy at our office.
Creekside Dental Financial Policy and AgreementFinancial Policy and Agreement • December 5th, 2007
Thank you for choosing us for your dental needs. We are committed to providing you with excellent care and convenient financial arrangements. Our financial arrangements are based on an open and honest discussion of recommended treatment options, respective fees and patients’ financial capabilities.
FINANCIAL POLICY AND AGREEMENT CHIROLINA CHIROPRACTICFinancial Policy and Agreement • July 5th, 2017
Definitions. In this Agreement, “Office” and “Clinic” shall refer to Chirolina Chiropractic, P. A. located at 2720 E WT Harris Blvd., Ste. 101“Financial Policy” or “Agreement” shall refer to this document.
Financial Policy and AgreementFinancial Policy and Agreement • April 4th, 2016
Thank you for choosing us as your healthcare provider. We are committed to providing you with the best possible medical care. Please understand that payment of your bill is considered a part of your treatment. The following is provided to avoid any misunderstanding or disagreement concerning payment for services, tests, and supplies provided by our office.
Financial Policy and AgreementFinancial Policy and Agreement • May 27th, 2016
Litchfield Dental Associates, LLCFinancial Policy and Agreement • March 10th, 2022
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • June 11th, 2020
Definitions, in this agreement, “Office” and “Clinic” shall refer to Douglas Smith, P.C., D.B.A. Advantage Chiropractic and Massage Therapy located at 400 Holiday Court, Suite 106, Warrenton, VA 20186. “Financial Policy” or “Agreement” shall refer to this document. “Payer” shall refer to a third-party payer/ insurance company.
Financial Policy and AgreementFinancial Policy and Agreement • November 24th, 2021
HINTON FAMILY DENTAL FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • February 19th, 2022
We, at Hinton Family Dental, are committed to providing you with the best care possible. As a condition of your treatment by this office, financial arrangements must be made in advance. Our dental practice is a small business. As such, the practice depends upon reimbursement from our patients for the costs incurred in their care to remain viable. We hope that understanding our financial policy will help to avoid any misunderstandings as we provide for your dental needs.
PHYSICAL THERAPY & SPORTS REHAB OF HASTINGS (PTSR) FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • April 20th, 2024
Thank you for choosing Physical Therapy & Sports Rehab of Hastings for your rehabilitation needs. We appreciate that you have entrusted us with your healthcare and are committed to providing you with the best patient care possible. The following explains our Financial Policy and Agreement which must be read and signed prior to any current or future medical evaluation or treatment in our office.
— FINANCIAL POLICY AND AGREEMENT —Financial Policy and Agreement • June 18th, 2013
Thank you for choosing us as your health care provider. We are committed to providing you with the best care possible. Please read the following information carefully and completely. Should you have any questions, please contact one of our staff immediately. Your clear understanding of our Financial Policy and Agreement is important to our professional relationship. You must sign and date this form prior to the beginning of care.
Financial Policy And AgreementFinancial Policy and Agreement • April 18th, 2018
The goal of Dr. Beaty and team is to make sure that you receive the highest quality dental care and service. One step is to make certain that our financial policies are clear and understood by you.
Financial Policy and Agreement and Cancellation PolicyFinancial Policy and Agreement • December 9th, 2024
The goal of TOTEM LAKE FAMILY DENTISTRY is to provide exceptional customer service and excellent dental care with both a professional and warm, personal touch. We want to make certain that our financial policies are clear and understood by you. If you have insurance, we will make a good faith estimate of your benefits and defer billing to you for that amount up to 60 days. We will file the appropriate claim forms with your insurance company, provided that you provide us with your personal information including social security number, ID number and date of birth. We will also assist you in understanding your dental plan benefits. If your insurer denies coverage, or if we otherwise do not receive payment within 60 days from the date services are rendered, the amount will then become due and payable by you. Please remember that your coverage is a contract between you and your insurer and/or your employer and your insurer. Although we will make every effort to help you obtain your benefits
FINANCIAL POLICY AND AGREEMENT MICHIANA WELLNESS & LONGEVITY CLINICFinancial Policy and Agreement • April 4th, 2013
Definitions. In this Agreement, “Office”, and “Clinic” shall refer to Michiana Wellness & Longevity Clinic located at 605 W. Edison Road, Mishawaka, IN 46545.
Brantley Chiropractic, P. C.Financial Policy and Agreement • May 17th, 2012
Please Print)Financial Policy and Agreement • May 3rd, 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 and AgreementFinancial Policy and Agreement • June 12th, 2024
Financial Policy and AgreementFinancial Policy and Agreement • October 27th, 2024
Thank you for choosing us as your health care provider. We are committed to providing you with the best care possible. Please read the following information carefully and completely. Should you have any questions, please contact us immediately. You must sign and date this form prior to the beginning of care.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • August 7th, 2013
Thank you for choosing Olympus Clinic for your health care provider. We are committed to excellent patient care and we are always working to improve the quality of treatment and service our patients receive. The following is an explanation of our financial policy, which you must read and sign prior to any medical evaluation or treatment.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • June 20th, 2017
Our office is committed to providing excellent, affordable medical care. You have the right and responsibility of knowing the cost of your medical treatment. Should you be a cash patient, we may not ask for full payment at the time of service, although you will remain responsible for the full payment of all fees for services provided. If you have health insurance, we bill your insurance company directly, and you will be responsible for co- payments, coinsurance, deductible, and/or non-covered amounts. For your convenience, our office accepts personal checks, credit cards, and cash. Please read the following carefully, as it outlines our financial policy. It is important that insurance patients understand how insurance billing works. Insurance companies require us to break down every component of your office visit into universal, numerical procedure codes, and charge for each code. The insurance companies will arbitrarily change, combine, and disallow procedure codes, and then apply the
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • January 19th, 2017
Our office is committed to providing excellent, affordable medical care. You have the right and responsibility of knowing the cost of your medical treatment. Should you be a cash patient, we may not ask for full payment at the time of service, although you will remain responsible for the full payment of all fees for services provided. If you have health insurance, we bill your insurance company directly, and you will be responsible for co- payments, coinsurance, deductible, and/or non-covered amounts. For your convenience, our office accepts personal checks, credit cards, and cash. Please read the following carefully, as it outlines our financial policy. It is important that insurance patients understand how insurance billing works. Insurance companies require us to break down every component of your office visit into universal, numerical procedure codes, and charge for each code. The insurance companies will arbitrarily change, combine, and disallow procedure codes, and then apply the
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • April 22nd, 2014
Parent/Child: The parent/legal guardian accompanying the child is responsible for payment at the time of service including co-payment. The parent/legal guardian with whom the child resides is the person who will be billed for services rendered- which may include: deductibles, co-pays, and any non-covered services provided. The parent/legal guardian is responsible for any balance after insurance has paid.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • February 11th, 2015
Definitions. In this Agreement, “Office” and “Clinic” shall refer Total Healing Experience, LLC, doing business as Dr. Melody Y. Matthews, located at 103 Twinridge Lane., North Chesterfield, VA 23235. “Financial Policy” or “Agreement” shall refer to this document.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • October 31st, 2017
Few things affect the quality of life as much as the comfort and confidence of comprehensive dental care. At ADANW, we are confident we provide a great value for our patients, providing personalized and high quality and high tech services, not only from Dr. Teasdale, but also from every member of our team. And although we will work with you always to obtain your greatest benefit from your dental insurance, or HSA/FSA accounts, we are not a financial institution and cannot guarantee insurance benefits and insurance payments. We appreciate that people have differing needs in fulfilling their financial obligations, and to help out, we offer the following payment options:
ContractFinancial Policy and Agreement • March 17th, 2020
Thank you for choosing Comstock Physical Therapy (CPT) as your physical therapy provider. The following explains our Financial Policy and Agreement which you must read and sign prior to any current and future medical evaluation or treatment in our office.
