Financial Policy and Patient AgreementFinancial Policy and Patient Agreement • September 11th, 2020
As a courtesy, I will bill your insurance company, HMO, responsible party, or third party payer for you. In the event you have not met your deductible, the full fee is due at each session until the deductible is satisfied. If your insurance company denies payment or does not cover counseling, I request that you pay the balance due at that time. If you make a payment by check and that check is returned for insufficient funds, your account will be charged a $35.00 fee. You agree that in the event your account is turned over to a collection agency or attorney due to non-payment, you will pay an additional 33.3 percent of the balance as reasonable collection fees (to be added to the balance at the time the account is placed for collection) plus any court costs and attorney's fees incurred in connection with the collection of your account. I ask that you authorize payment of medical benefits directly to K&B Counseling Services, LLC (the Practice).
Financial Policy, Fee Schedule and Patient AgreementFinancial Policy and Patient Agreement • January 10th, 2021
Generally, acute conditions respond more quickly than chronic conditions. I also encourage follow up care to prevent symptoms from recurring and to maintain wellness. Patients will usually begin to see positive changes within the first few treatments.
FINANCIAL POLICY AND PATIENT AGREEMENTFinancial Policy and Patient Agreement • June 11th, 2024
PAYMENT IS EXPECTED AT THE TIME OF SERVICE FOR THE PATIENT’S PORTION OF THE CHARGES. WE ACCEPT CASH, CHECKS, AND MOST MAJOR CREDIT CARDS FOR YOUR CONVENIENCE. WE REQUIRE YOU TO READ THE FINANCIAL POLICY AND THE SURPRISE BILLING ACT ENTIRELY AND SIGN BEFORE TREATMENT.
Financial Policy and Patient Agreement (Revised 10/2013)Financial Policy and Patient Agreement • May 10th, 2013
You are financially responsible for the services we provide to you. We understand that many patients arrange for insurance companies to pay for a large portion of medical claims. However, the patient (or legal guardian if the patient is a minor) is ultimately responsible for the bill if the insurance company does not pay.
FINANCIAL POLICY AND PATIENT AGREEMENTFinancial Policy and Patient Agreement • April 4th, 2017
The following is the Financial Policy for Richard D Wolff, DPM. We are committed to giving you the best care possible. We expect, in return, that you have the same commitment to your medical and financial responsibility to us.
FINANCIAL POLICY AND PATIENT AGREEMENT LIFETIME AUTHORIZATIONFinancial Policy and Patient Agreement • June 13th, 2024
This is the financial policy of the Cherry Creek Eye Physicians and Surgeons (Practice), which we require to be read and signed prior to treatment:
Financial Policy and Patient AgreementFinancial Policy and Patient Agreement • July 5th, 2023
Elysium Health and Wellness is committed to delivering expert care with soul. To give you the best care possible we, in turn, ask that you are on time for appointments. At Elysium we start on time! So if you’re appointment is at 10:00 am, get here at 9:50 am to check in, verify your insurance, be called back, have your vitals taken, and verify your medication list. All new patients please arrive 20 minutes early. The doctor should be walking in the door to greet you at your appointment time. Please call to cancel an appointment as soon as possible if you know you can’t make it. Being late for your appointment means less time with the doctor and the only way to get good care is adequate time!
FINANCIAL POLICY AND PATIENT AGREEMENTFinancial Policy and Patient Agreement • February 16th, 2022
Any co-payments specified by your insurance company must be paid at the time of service, as is stated by your insurance company and can not be billed at a later date. Acceptable forms of payment are cash, personal check, money order, credit card, or CareCredit. You will also be responsible for payment of any charges that your insurance company applies towards your deductible and will be billed accordingly. Our office will call your insurance company and attempt to obtain your benefit and eligibility information prior to your appointment; however, we are not always given accurate information.
FINANCIAL POLICY AND PATIENT AGREEMENTFinancial Policy and Patient Agreement • June 21st, 2022
PAYMENT IS EXPECTED, AT THE TIME OF SERVICE, FOR "YOUR PART" OF THE CHARGES. WE ACCEPT CASH, CHECKS, AND MOST MAJOR CREDIT CARDS FOR YOUR CONVENIENCE. WE REQUIRE YOU TO READ THE FINANCIAL POLICY AND THE SURPRISE BILLING ACT ENTIRELY AND SIGN BEFORE TREATMENT.
FINANCIAL POLICY AND PATIENT AGREEMENTFinancial Policy and Patient Agreement • October 12th, 2010
The following is the Financial Policy for Colorado Springs Orthopaedic Group. We are committed to giving you the best care possible; we expect, in return, that you have the same commitment to your medical and financial responsibility to us.
FINANCIAL POLICY AND PATIENT AGREEMENTFinancial Policy and Patient Agreement • July 14th, 2023
PAYMENT IS EXPECTED, AT THE TIME OF SERVICE, FOR PATIENT’S PORTION OF THE CHARGES. WE ACCEPT CASH, CHECKS, AND MOST MAJOR CREDIT CARDS FOR YOUR CONVENIENCE. WE REQUIRE YOU TO READ THE FINANCIAL POLICY AND THE SURPRISE BILLING ACT ENTIRELY AND SIGN BEFORE TREATMENT.
Sound Acupuncture PLLCFinancial Policy and Patient Agreement • November 15th, 2018
Please take a moment to review our financial policy and fee schedule and sign the agreement below: This office accepts Cash, Checks, and Credit/Debit Cards
FINANCIAL POLICY AND PATIENT AGREEMENTFinancial Policy and Patient Agreement • July 14th, 2017
By signing below I understand biopsy/biopsies may be performed. Biopsies are generally billed by Skin Cancer and Dermatology Center to my insurance. In some cases, the biopsy/biopsies may be sent directly to an outside laboratory or for a second opinion. I understand the outside laboratory will bill my insurance directly and I may be liable for the additional cost incurred.
FINANCIAL POLICY AND PATIENT AGREEMENTFinancial Policy and Patient Agreement • May 9th, 2020
The patient also authorizes the exchange of information relating to care and claims with the patient’s insurance companies, its intermediaries, carriers, referring physician, and primary care physicians. The patient authorizes insurance payments to be made directly to the Practice for services provided. Payment by the insurance company sent straight to the patient must be reimbursed by the patient to the Practice. By signing below, I authorize and consent to examination, treatments, and procedures, which, by the assessment of my physician, may be considered necessary or advisable for diagnosis or treatment of my case. Regardless of if my insurance pays for the services, I understand I am financially responsible. I authorize any credit amounts, irrespective of the date paid, applied to any balance due on my account.
