ContractInsurance and Payment Agreement • June 10th, 2022
!ank you for choosing Heart Rhythm Solutions (HRS) as your health care provider; we are committed to your treatment being successful! By signing below, you authorize your insurance company to release any information required to process claims and pay insurance benefits directly to HRS. Please review and sign this Insurance and Payment Agreement prior to services being rendered.
INSURANCE AND PAYMENT AGREEMENTInsurance and Payment Agreement • June 22nd, 2019
By signing this document, I certify that the dental insurance information provided to Point Family Dentistry is correct and currently in effect.
ALIGN SPINE HEALTH CENTER, LLC 8555 16TH STREET, SUITE 800 SILVER SPRING, MD 20910Insurance and Payment Agreement • April 16th, 2014
The doctor’s service is provided directly to you and not to Insurance Company. However, as a courtesy to our patients, we bill your insurance company for you. If your insurance company does not respond with payment within 45 days of claim submission we will expect you to pay the balance of your bill in full. If you present a card that is not your insurance coverage or that the coverage is not in effect at the time if service it will be considered fraud and it is punishable by law.
