Dr. Nancy Aria - Office Policy Agreement FormOffice Policy Agreement • January 16th, 2019
• (initials) I understand that it is my responsibility to provide the doctor with my current and accurate insurance card and a valid referral, if required by my insurance, at the time services are rendered. If I cannot provide my current insurance card and/or referral, my appointment may be rescheduled. Claims that are denied for payment because of incorrect insurance information will become the responsibility of the patient.
Office Policy AgreementOffice Policy Agreement • December 14th, 2018
OFFICE POLICY AGREEMENTOffice Policy Agreement • December 9th, 2016
Thank you for choosing Fall Creek Internal Medicine, LLP for your health care. We are committed to providing you with quality, personal health care, and appreciate your commitment to adhere to this Office Policy Agreement. Agreement with this policy is required for all medical care.
Office Policy AgreementOffice Policy Agreement • October 13th, 2016
(Including co-payments, deductibles, and any/all portions not covered by insurance). If extensive treatment is necessary we offer 4 different in-office payment options for balances over $300. Dr. Manning participates with the financial plan CitiHealthcard at
Office Policy Agreement / HIPAA NoticeOffice Policy Agreement • March 15th, 2021
Empire Dental P.C. takes pride in providing “The Ultimate Patient Experience”. Our Patients receive the upmost respect and consideration. It is important that your account is up to date and current. We are committed to keeping the cost of care affordable. The fees quoted are estimated only based on the information provided by you and the insurance company.
