PATIENT FINANCIAL AGREEMENT & ACKNOWLEDGEMENT OF OFFICE POLICIESPatient Financial Agreement • May 28th, 2020
Ophthalmology Associates believes that part of good health care practice is to establish and communicate an office and financial policy to our patients. We are dedicated to providing the best possible care for you, and we want you to have a full understanding of our policies.
Patient Financial AgreementPatient Financial Agreement • October 16th, 2020
Please read the following information closely. If you have any questions, please ask. We want to ensure that you completely understand our financial policies.
Patient Financial AgreementPatient Financial Agreement • February 16th, 2021
Financial Policy Patient Financial AgreementPatient Financial Agreement • October 15th, 2020
Summit Medical Clinic, P.C. is committed to serving our patients with professionalism and caring and from our patients we expect the same commitment. This includes being on time for your appointment and calling to cancel an appointment if you can’t make it. It also includes financial responsibility, like presenting your identification and insurance cards at every appointment and making your copay and deductible payments at the time of your office visit with cash, check, or credit card.
Patient Financial AgreementPatient Financial Agreement • September 20th, 2021
(Please fully read, sign on back, and return to the receptionist. We will be happy to furnish you with another copy for your records. It is also available on the website.)
Patient Financial AgreementPatient Financial Agreement • December 28th, 2018
Patient Financial AgreementPatient Financial Agreement • November 29th, 2022
HEALTH FIRST COLORADO PATIENT FINANCIAL AGREEMENT AND GUARANTEEPatient Financial Agreement • November 3rd, 2021
I, the undersigned, acknowledge that not all services provided to me by Endocrinology Specialists of Colorado, LLC (“Provider”) are covered or reimbursable by my insurance plan, including Colorado’s medical assistance program, the Health First Colorado Medicaid Plan (the “Plan”). I acknowledge and accept that I am financially responsible for all services and items rendered on my behalf by the Provider by which a charge may be associated and which is not covered and/or not reimbursable. I agree to give the Provider complete and accurate insurance information for primary and secondary insurance coverage and all identification and benefit cards/ documents required for claim accuracy.
Patient Financial AgreementPatient Financial Agreement • October 20th, 2017
PATIENT FINANCIAL AGREEMENT & ACKNOWLEDGEMENT OF OFFICE POLICIESPatient Financial Agreement • January 26th, 2022
Thank you for choosing us as your health care provider. We are committed to providing quality care and service to all of our patients. United Physician Group (“UPG”) believes that part of good health care practice is to establish and communicate an office and financial policy to our patients proactively and effectively. We are dedicated to providing the best possible care for you, and we want you to have a full understanding of our policies.
EDGEFIELD MEDICAL CENTERPatient Financial Agreement • March 2nd, 2021
EDGEFIELD MEDICAL CENTERPatient Financial Agreement • October 6th, 2020
Patient Financial Agreement and ResponsibilitiesPatient Financial Agreement • October 25th, 2022
Piedmont Healthcare is committed to providing patients with information regarding their coverage and financial responsibilities. In consideration of services provided by Piedmont Healthcare (PHC), the Patient or undersigned representative acting on behalf of the Patient agrees to the following:
SHCC 340B & Patient Financial AgreementPatient Financial Agreement • September 3rd, 2020
The following is an agreement to provide Cloney’s pharmacy with credit/debit card information upon pick-up of those medications at SHCC:
Patient’s Financial Agreement: Reconstructive Foot Surgeon, LLC (Dr. Ned M. Ramadan, DPM)Patient Financial Agreement • July 20th, 2021
Our practice philosophy is that the doctor-patient relationship is a partnership in which our common goal is working towards your health and wellness. As a partner in your care, it is important for you to understand your insurance benefits and financial obligations. Your insurance policy is an arrangement between you and your insurance company. This is not something which we have any influence over.
PATIENT FINANCIAL AGREEMENTPatient Financial Agreement • April 14th, 2020
Arizona Eye Consultants is committed to serving our patients with professionalism and caring. We ask the same from you. This includes:
PATIENT FINANCIAL AGREEMENTPatient Financial Agreement • November 28th, 2016
Co-payments are due at the time of service. If you are unable to remit your co-payment amount, the office reserves the right to reschedule your appointment for another day/time that is convenient for you. If you wish to be seen at your regularly scheduled appointment the practice reserves the right to bill an additional $20.00 fee if the copay is not remitted by the end of the business day.
Patient Financial AgreementPatient Financial Agreement • August 26th, 2024
● As a courtesy to you, we will file the insurance claim for you if you assign the benefits to the doctor. In other words, you agree to have your insurance company pay the doctor directly.
California Orthopaedic Specialists 360 San Miguel Drive #701 Newport Beach, CA 92660Patient Financial Agreement • February 17th, 2022
Our goal is to provide you with the best medical care available. A clear understanding of our financial arrangements is essential for a successful doctor/patient relationship.
Bright Skies Therapy Center, LLC Financial Policy and Patient Financial AgreementPatient Financial Agreement • May 16th, 2019
Bright Skies Therapy Center is committed to serving our patients with care and professionalism and from our patients we expect the same commitment. This includes financial responsibility. Your responsibility is to provide us with accurate and complete information concerning your primary and secondary insurance medical benefits, including referral documents from other providers. Current identification and insurance benefit cards are to be presented at each office visit. As a courtesy, Bright Skies Therapy Center will file your insurance claim for you.
PATIENT FINANCIAL AGREEMENTPatient Financial Agreement • March 7th, 2011
Patient Financial AgreementPatient Financial Agreement • August 18th, 2021
Please read the below terms and conditions in this Patient Financial Agreement (“Agreement”) carefully as it is our intent with this policy to outline patient and practice financial responsibilities and obligations fairly and clearly. You will be asked to sign this document. This Agreement will remain in full force and effect unless modified by Physician’s for Women’s Health, LLC, its successors, and assigns.
Patient Financial AgreementPatient Financial Agreement • February 25th, 2024
PATIENT FINANCIAL AGREEMENTPatient Financial Agreement • December 31st, 2014
We strive to maintain a strong physician-patient relationship. Sharing our Financial Policy in advance allows for a good flow of communication and enables us to achieve our goal. If you have any questions, do not hesitate to ask a member of our staff.
Patient Financial AgreementPatient Financial Agreement • October 16th, 2020
Please read the following information closely. If you have any questions, please ask. We want to ensure that you completely understand our financial policies.
Patient Financial AgreementPatient Financial Agreement • November 2nd, 2020
(Please fully read, sign on back, and return to the receptionist. We will be happy to furnish you with another copy for your records. It is also available on the website.)
Jane Brown, Psy.D.Patient Financial Agreement • September 8th, 2021
evaluation in the amount of $300 dollars per hour for all test administration, data collection, scoring and inter- pretation, collateral interviews (in person or via phone), written report, and feedback sessions. There is no charge for local travel, emails, text messages, or phone calls of less than 20 minutes. I understand that Dr.
Patient Financial AgreementPatient Financial Agreement • May 2nd, 2016
• Benson Health Clinic participates with Medicare, Medicaid and Commercial Insurances. While Benson Health Clinic may have an agreement with your insurance, it is your responsibility to know if your plan is in network. Benson Health Clinic makes every effort to verify your insurance eligibility, deductible amounts, and co-insurance amounts prior to your initial visit. However, we cannot guarantee the amount stated, as the benefits quoted to us by your insurance are not necessarily a guarantee of payment. Many insurance companies have additional stipulations that may affect your coverage. It is your responsibility to understand and comply with any predetermination of benefits or referral requirements. Please be aware that some, and perhaps all, of the services provided may be non-covered services or may not be considered necessary under your medical insurance company. By contract, covered charges will be paid directly to Benson Health Clinic. Any Applicable co-payment, co-insurance paym
Patient Financial AgreementPatient Financial Agreement • September 22nd, 2020
We would like to take this opportunity to Thank-you for choosing Pediatric Neurologists of Palm Beach to provide your child’s neurological care.
ContractPatient Financial Agreement • October 17th, 2021
Patient Financial Agreement Thank you for choosing PRIME MD OF NAPLES as your health care provider. We are committed to building a successful physician- patient relationship with you and your family. Your clear understanding of our Patient Financial Policy is important to our professional relationship. Please understand that payment for services is a part of that relationship. Please ask if you have any questions about our fees, our policies, or your responsibilities. It is your responsibility to notify our office of any patient information changes (i.e., address, name, insurance information, etc). Co-pays The patient is expected to present an insurance card at each visit. All co-payments and past due balances are due at time of check-in unless previous arrangements have been made with a billing coordinator. We accept cash, check or credit cards. Absolutely no post- dated checks will be accepted. Insurance Claims Insurance is a contract between you and your insurance company. In mos
Patient Financial Agreement and Assignment of BenefitsPatient Financial Agreement • December 27th, 2023
MAEDOT SEMO, D.M.D.Patient Financial Agreement • May 20th, 2020
In our effort to provide you with comprehensive, evidence-based dentistry that consistently exceeds the standard of care, it is imperative that you have a clear understanding of our financial policy. This Financial Agreement is in line with our philosophy of being informative, honest and forthright with regards to your financial responsibility. In the process, we also strive to provide you with an understanding of the role of dental insurance as it pertains to your treatment needs.
PATIENT FINANCIAL AGREEMENTPatient Financial Agreement • March 23rd, 2017
Our Mission is to improve the health of our community by providing high quality, caring, culturally appropriate health care that addresses the needs of people regardless of their ability to pay.
David E Vitunac, D.M.D.Patient Financial Agreement • August 16th, 2021
This agreement is to inform you of your financial obligation to our practice. We are committed to providing you with the highest quality dental care using only the best material and technology available in the market today. We are also committed to providing you with up-to-date information and educational tools so you may fully participate in maintaining optimum oral health.
Patient Financial AgreementPatient Financial Agreement • October 12th, 2021
This document is a breakdown of Health Travel, Immunizations, and Physicals financial policies and an explanation of potential charges you could owe related to services at our office. Actual amounts vary depending on the type of service provided and your health insurance coverage at the time of service. This list is not comprehensive and may be updated without prior notice.
