Patient Financial Policy AgreementPatient Financial Policy Agreement • April 30th, 2021
Thank you for choosing the Spine Institute of Central Florida as your health care provider. We are committed to providing you with the best possible care. Payment of your bill is considered a part of our professional relationship and a clear understanding of our financial policy is important.
Patient Financial Policy AgreementPatient Financial Policy Agreement • June 10th, 2016
Thank you for choosing the Spine Institute of Central Florida as your health care provider. We are committed to providing you with the best possible care. Payment of your bill is considered a part of our professional relationship and a clear understanding of our financial policy is important.
PATIENT FINANCIAL POLICY AGREEMENTPatient Financial Policy Agreement • October 22nd, 2021
Insurance: It is your responsibility to provide Kaukauna Clinic, S.C. with current insurance information. We will ask for your insurance card at each visit and keep a copy in your chart. Please bring your current insurance card with you every time you visit our office.
Patient Financial Policy AgreementPatient Financial Policy Agreement • March 28th, 2019
We are committed to providing you with quality healthcare and would appreciate your commitment to adhere to this Financial Policy Agreement. Please read this policy carefully and sign the Acknowledgement section at the bottom of this form. Please do not hesitate to ask a member of our staff if you have any questions.
Patient Financial Policy AgreementPatient Financial Policy Agreement • August 8th, 2024
The patient is expected to present an insurance card at each visit. All co-payments and past due balances are due and payable at the time of service. Payments may be made with credit cards, debit cards, or personal check.
Patient Financial Policy AgreementPatient Financial Policy Agreement • October 16th, 2023
North Branch Dermatology LLC is committed to serving our patients with the best medical care and we expect the same commitment from our patients. This includes being on time for your appointment and calling to cancel an appointment if you are unable to make it. If you do not notify us that you will not be able to attend a scheduled appointment a $25 fee may be billed to you. The patient should be ready to present their current insurance cards at every appointment and making their copay payments at the time of the office visit.
Patient Financial Policy AgreementPatient Financial Policy Agreement • March 28th, 2019
We are committed to providing you with quality healthcare and would appreciate your commitment to adhere to this Financial Policy Agreement. Please read this policy carefully and sign the Acknowledgement section at the bottom of this form. Please do not hesitate to ask a member of our staff if you have any questions.
ContractPatient Financial Policy & Agreement • November 9th, 2016
Please read and sign this agreement before we agree to accept assignment directly from your insurance company. This avoids any misunderstandings and facilitates the processing of your insurance claims. If you have any questions, please ask us. Hudson Family Dental is in network with: Delta Dental Premier, BlueCross Blue Shield & Cigna.
Patient Financial Policy AgreementPatient Financial Policy Agreement • June 10th, 2024
The patient is expected to present an insurance card at each visit. All co-payments and past due balances are due and payable at the time of service. Payments may be made with credit cards, debit cards, or personal check.
PATIENT FINANCIAL POLICY AGREEMENT AND AUTHORIZATION/CONSENT FOR TREATMENTPatient Financial Policy Agreement • December 3rd, 2020
Copays: The patient is expect to present an insurance card at each visit. All copayments and past due balances are due and payable at the time of service. Initials Self Pay Accounts: Self pay accounts are patients who are covered by insurance plans that Family Medical Center does not participate in, patients without an insurance card on file or at the time of service. It is expected that payment is required at time of service. Initials Automobile Accident cases or Third Part Liability Claims: The patient will treated as a self pay account. The patient is expected to pay for services in full at time of service. Initials Divorce and/or Child Custody cases: In the case of divorce, the individual who initiates care for the child, is responsible for payment of copays, coinsurance and non participating insurance balances at the time of service. We will not bill a divorced spouse for the patients care.
Costas A. Apostolis, MDPatient Financial Policy Agreement • January 5th, 2019
We are committed to providing you with the best possible care and we are pleased to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy, or your relationship as our patient. We file insurance claims as a courtesy to our patients. The guidelines below help you assist us with this process.
