WESTERN WASHINGTON MEDICAL GROUP FAMILY MEDICINEOffice/Financial Agreement • June 25th, 2019
We consider all patients as “private” unless their insurance is one whom with we have a contractual agreement. We will bill your insurance as a courtesy but the balance for “private” patients is due and payable within 30 days. Many insurance plans cover a certain percentage only of the fees charged. The insurance normally only covers the “usual and customary” fees. Your insurance, as a result, may cover less than you thought they might or you may have a deductible to meet first. You may have scheduled a visit that is not covered by your insurance, such as Preventative Care, it is the patient’s responsibility to check their benefits prior to being seen.
Office Financial AgreementOffice Financial Agreement • September 21st, 2021
OFFICE FINANCIAL AGREEMENTOffice Financial Agreement • January 3rd, 2020
Thank you for choosing us as your dental 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 which we require that you read and sign prior to any treatment.
OFFICE FINANCIAL AGREEMENTOffice Financial Agreement • November 17th, 2020
Thank you for choosing us as your dental 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 which we require that you read and sign prior to treatment.
Office Financial AgreementOffice Financial Agreement • April 1st, 2021
Payment is due at the time services are rendered. For your convenience we accept cash, personal check, Visa, MasterCard, Discover, or American Express.
Myrtle Avenue Pediatrics 2019 Office Financial AgreementOffice Financial Agreement • September 13th, 2021
The information that I have given is correct to the best of my knowledge. I understand that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical insurance status. I certify that my child has health insurance currently in force as detailed above. I assign directly to Myrtle Avenue Pediatrics all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I herby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic. I, the undersigned, agree to be financially responsible.
OFFICE FINANCIAL AGREEMENTOffice Financial Agreement • January 29th, 2015
At Conner Dental Associates we are committed to providing you with quality dental care. A clear understanding of your financial responsibility is important to our professional relationship. (Please note that all office fees are subject to change).
ContractOffice Financial Agreement • November 22nd, 2020
The information that I have given is correct to the best of my knowledge. I understand that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical insurance status. I certify that my child has health insurance currently in force as detailed above. I assign directly to Lori McAuliffe, M.D., P.A. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic. I, the undersigned, agree to be financially responsible:
Office Financial AgreementOffice Financial Agreement • September 13th, 2010
Cash patients must pay, in full, at the time of service. A discount of 20% will be given for the office visit portion of the total charge. We accept cash, check, VISA, Mastercard, American Express, and Discover.
Office Financial AgreementOffice Financial Agreement • January 21st, 2020
Samuel W. Galstan, DDS, MPH, MAGDOffice Financial Agreement • May 31st, 2021
SERGEANT BLUFF DENTAL RENEE L. HUSEN, D.D.S. SCOTT T. WILMES, D.D.S.Office Financial Agreement • June 14th, 2018
Insurance benefits are determined by your employer and not your dentist. Any deductible or estimated co-payment amount will be due at the time of treatment. Insurance is not a guarantee of payment; insurance companies will not pay for all your costs. Your insurance policy is a contract between you and your insurer. Your insurance and payment are still your responsibility. As a courtesy we will be glad to file your claim for you if you bring 1) your dental insurance card and 2) all required employer information. You will be expected to pay for services rendered if the office is unable to verify your insurance information before treatment. If payment for services already rendered has not been paid in full within 90 days, either by you or your insurance company, the remaining balance for treatment is considered due and collectible.
Milford Dental Clinic, P. C. Office Financial AgreementOffice Financial Agreement • August 3rd, 2016
Insurance benefits are determined by your employer and not your dentist. Any deductible or estimated co-payment amount will be due at the time of treatment. Insurance is not a guarantee of payment; insurance companies will not pay for all your costs. Your insurance policy is a contract between you and your employer. Your insurance and payments are still your responsibility. As a courtesy, we will be glad to file your claim for you, if you bring all required insurance information. You will be expected to pay for services rendered if the office is unable to verify your insurance information before treatment. If payment for services already rendered has not been paid in full within 45 days, either by you or your insurance company, the remaining balance for treatment is considered due and collectible.
OFFICE FINANCIAL AGREEMENTOffice Financial Agreement • July 11th, 2022
Thank you for choosing us as your dental 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 which we require that you read and sign prior to any treatment.
Office Financial AgreementOffice Financial Agreement • October 26th, 2011
The following describes our financial policy. All patients are ultimately responsible for payment of all charges and must sign this AGREEMENT, a copy of which will be kept in your record.
Dr. Joseph G. Vaughan 130 Cedar KnollOffice & Financial Agreement • September 21st, 2021
Statements: If you have a balance on your account, we will send you a monthly statement. It will show separately the previous balance, any new charges to the account, and any payments or credits applied to your account during the month. After 60 days your account will be charged a 5% finance charge for all unpaid estimated portions owed by you but not yet paid. This finance charge will accrue monthly until the balance is paid in full.
Office Financial AgreementOffice Financial Agreement • November 20th, 2020
The following describes our financial policy. All patients are ultimately responsible for payment of all charges and must sign this AGREEMENT, a copy of which will be kept in your record.
