Standard Contracts
Patient Financial PolicyPatient Financial Policy • December 16th, 2019
This is an agreement between Summit Primary Care dba AdvancedHEALTH, as creditor, and the Patient/Debtor named on this form and indicated by patient/debtor signature below.
This is an agreement between South Lane PhysicalPatient Financial Policy • October 20th, 2022
In this agreement the words “you”, “your”, and “yours” mean the Patient (debtor). The word “account” means the account that has been established in your name to which charges are made and payments are credited. The words “we”, “us” and “our” refer to South Lane Physical Therapy, LLC.
Gainesville Heart and Vascular Group Patient Financial PolicyPatient Financial Policy • December 20th, 2023
We require that you read and sign this financial policy. This policy is effective 06/20/2013. In this agreement, the words “you,” your,”, and “yours” mean the patient/debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words “we,” “us,” and “our” refer to Gainesville Heart and Vascular Group, P.C.. It is the policy of this office to help keep your healthcare costs as low as possible. To do this, we need to keep our billing costs to a minimum. Please help us in the following ways:
Patient Financial PolicyPatient Financial Policy • February 10th, 2021
This is an agreement between AdvancedHEALTH, as creditor, and the Patient/Debtor named on this form and indicated by patient/debtor signature below.
Patient Financial PolicyPatient Financial Policy • September 16th, 2020
This is an agreement between AdvancedHEALTH, as creditor, and the Patient/Debtor named on this form and indicated by patient/debtor signature below.
Hoosier Foot and Ankle Financial Policy Please read below and initial on line next to each policy and sign agreement. Patient Financial PolicyPatient Financial Policy • August 15th, 2019
____ You must complete a New Patient Registration form providing all personal information required and complete any insurance information as required on the form. This information must be provided to the office at least 2 days prior to your appointment for verification of medical insurance. In the event the office is not provided with this information, you will be responsible for all charges not covered by your insurance. Hoosier Foot and Ankle will attempt to verify insurance benefits and eligibility prior to your visit; however, these verifications are NOT a guarantee of payment.
Patient Financial PolicyPatient Financial Policy • August 14th, 2013
We would like to thank you for choosing Speech Therapy Associates as your health care provider. This is an agreement between Speech Therapy Associates and you, the patient. By signing this agreement, you are agreeing to pay for all services provided to you and on your behalf by Speech Therapy Associates.
Patient Financial Policy ~ Privacy PracticesPatient Financial Policy • April 18th, 2019
This is an agreement between Renaissance/Dr. Matthew M. Akers and the Patient/Debtor (Account) named on this form. The account is established in your name to which charges are made and payments credited.
F aith Family Medical Services, LLC Patient Financial PolicyPatient Financial Policy • January 3rd, 2011
Your signature below forms a binding agreement between Faith Family Medical Services and the Patient who is receiving medical services or the Responsible Party for minor patients (those patients under the age of 18 years old). Responsible Party is the individual who is financially responsible for payment of medical bills.
Gainesville Heart Group Patient Financial PolicyPatient Financial Policy • September 18th, 2009
We require that you read and sign this financial policy. This policy is effective 01/01/2009. In this agreement, the words “you,” your,”, and “yours” mean the patient/debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words “we,” “us,” and “our” refer to Gainesville Heart Group,pc. It is the policy of this office to help keep your healthcare costs as low as possible. To do this, we need to keep our billing costs to a minimum. Please help us in the following ways:
Patient Financial PolicyPatient Financial Policy • January 15th, 2020
This is an agreement between Premier Radiology | Ascension, as creditor, and the Patient/Debtor named on this form and indicated by patient/debtor signature below.
Patient Financial PolicyPatient Financial Policy • July 6th, 2016
This is an agreement between AdvancedHEALTH, as creditor, and the Patient/Debtor named on this form and indicated by patient/debtor signature below.
Patient Financial PolicyPatient Financial Policy • August 27th, 2020
This is an agreement between AdvancedHEALTH dba VeinCare Centers of Tennessee, as creditor, and the Patient/Debtor named on this form and indicated by patient/debtor signature below.
Patient Financial PolicyPatient Financial Policy • November 1st, 2021
This is an agreement between Ada Dermatology and the Patient/Guarantor named below. By signing this agreement, you are acknowledging that you understand our insurance and financial policies and are agreeing to pay for all services that are received.
