PATIENT FINANCIAL RESPONSIBILITY AGREEMENTPatient Financial Responsibility Agreement • June 23rd, 2021
Thank you for choosing Psychiatric, Health & Wellness (PHW) LLC as your healthcare provider. The medical services you seek imply an obligation on your part to ensure payment is made in full for services received. The Patient Financial Responsibility Agreement (“Agreement”) will assist you in understanding your financial responsibility. Feel free to ask questions. If someone else (parent, spouse, domestic partner, etc.) is financially responsible for your expenses, please share this Statement with them, as it explains to our practice financial policy. The financially responsible person signing this agreement must be eighteen (18) years or older and be employed.
PATIENT FINANCIAL RESPONSIBILITY AGREEMENTPatient Financial Responsibility Agreement • July 13th, 2023
Please note that this agreement states your financial responsibility as a patient of Curtis Takemoto- Gentile, MD or Krishanna Takemoto-Gentile, MD “Dr. Curtis Takemoto-Gentile, MD Inc” and addresses the possibility of incurring out of pocket expenses.
Patient Financial Responsibility AgreementPatient Financial Responsibility Agreement • September 3rd, 2014
**Please note that this agreement states your financial responsibility as a patient of Hawaii Pacific Neurosci- ence, LLC, and addresses the possibility of incurring out of pocket expenses.
Patient Financial Responsibility AgreementPatient Financial Responsibility Agreement • August 14th, 2017
We value the relationship we have with you and your children. Advising you in advance of our office policy for financial obligations allows for a good flow of communication. Please read and sign this agreement. If there are questions regarding any of this content, please do not hesitate to ask a member of our billing team.
Patient Financial Responsibility AgreementPatient Financial Responsibility Agreement • January 29th, 2021
In order to avoid unexpected charges, you should reach out to your insurance carrier before you initiate treatment here to familiarize yourself with the limits of your policy, and what it will and will not provide coverage for. We do our best to guide patients through this process, but ultimately it is impossible for us to keep abreast of the requirements and stipulations of the thousands of insurance products on the market. It is an individual patient responsibility to understand the provisions, limits, and requirements of their individual benefit plan(s) and advise us accordingly.
HST PATIENT FINANCIAL RESPONSIBILITY AGREEMENTPatient Financial Responsibility Agreement • August 19th, 2020
If you have a deductible plan that has not been met yet you will be responsible for the full allowed amount until it is met. Any overpayments will be applied to any following appointments or refunded in full.
Patient Financial Responsibility AgreementPatient Financial Responsibility Agreement • September 11th, 2024
PATIENT FINANCIAL RESPONSIBILITY AGREEMENTPatient Financial Responsibility Agreement • May 27th, 2020
PATIENT FINANCIAL RESPONSIBILITY AGREEMENTPatient Financial Responsibility Agreement • April 27th, 2023
The medical services you seek here imply an obligation on your part to ensure payment in full is made for services you receive. This Patient Financial Responsibility Agreement will assist you in understanding that financial responsibility.
PATIENT FINANCIAL RESPONSIBILITY AGREEMENTPatient Financial Responsibility Agreement • November 15th, 2015
Thank you for choosing Bend Osteopathic Care, PC to assist you in your medical needs. We are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understandingof our patient financial policies.
Patient Financial Responsibility AgreementPatient Financial Responsibility Agreement • May 19th, 2024
The doctors and staff of Slade & Baker Vision Center appreciate the confidence you have shown in choosing them to provide for your medical needs. We are committed to providing you with the highest quality healthcare. Please read and sign this form to acknowledge your understanding of our patient financial policies.
PATIENT FINANCIAL RESPONSIBILITY AGREEMENTPatient Financial Responsibility Agreement • April 12th, 2022
Thank you for choosing Psychiatric, Health & Wellness (PHW) LLC as your healthcare provider. The medical services you seek imply an obligation on your part to ensure payment is made in full for services received. The Patient Financial
Patient Financial Responsibility AgreementPatient Financial Responsibility Agreement • August 3rd, 2020
We value the relationship we have with you and your children. Advising you in advance of our office policy for financial obligations allows for a good flow of communication. Please read and sign this agreement. If there are questions regarding any of this content, please do not hesitate to ask a member of our billing team.
PATIENT FINANCIAL RESPONSIBILITY AGREEMENTPatient Financial Responsibility Agreement • November 6th, 2017
The medical services you seek here imply an obligation on your part to ensure payment in full is made for services you receive. This Patient Financial Responsibility Agreement will assist you in understanding that financial responsibility.
PATIENT FINANCIAL RESPONSIBILITY AGREEMENTPatient Financial Responsibility Agreement • August 17th, 2020
Thank you for choosing Bend Osteopathic Care, PC to assist you in your medical needs. We are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our patient financial policies.
PATIENT FINANCIAL RESPONSIBILITY AGREEMENTPatient Financial Responsibility Agreement • March 29th, 2020
Your signature below forms a binding agreement between, on the one hand, SARAH FISHMAN, M.D. PhD PC (the “Practice”) and, on the other hand, the undersigned Patient who is receiving medical services or the undersigned Responsible Party for patients under 18 years old or holding other legal representative status. The Responsible Party is the individual who is financially responsible for payment of medical bills. This includes all fees for medical visits, procedures, and tele-health communications.
PATIENT FINANCIAL RESPONSIBILITY AGREEMENTPatient Financial Responsibility Agreement • May 1st, 2023
Thank you for choosing Fox Eye Care Group (FECG) as your eyecare provider! The services you seek here imply an obligation on your part to ensure payment in full is made for the services you receive. This Patient Financial Responsibility Agreement will assist you in understanding that financial responsibility.
Patient Financial Responsibility Agreement-Patient Financial Responsibility Agreement • May 11th, 2013
• As a courtesy to you, we will gladly bill your insurance for services however, you, the patient, have a contract with your insurance carrier. We cannot guarantee that your insurance will cover our services. You are required to present your current insurance card and picture ID at the front desk at each visit so we can verify your current information. Please inform us of any and all insurance you possess, and of any recent changes. All charges are ultimately your responsibility, regardless of insurance coverage or payment problems. You are responsible for payment of any and all copayments, deductibles, coinsurance and out-of-pocket expenses incurred, including fees for services not covered under your insurance policy.
Patient Financial Responsibility AgreementPatient Financial Responsibility Agreement • September 24th, 2023
YOU MUST PROVIDE YOUR PICTURE IDENTIFICATION TO THE RECEPTIONIST FOR PHOTOCOPYING AT EACH APPOINTMENT. THIS ACCOUNT IS SELF-PAY, AND PAYMENT IN FULL IS DUE AT THE TIME OF EACH SERVICE.
Patient Financial Responsibility AgreementPatient Financial Responsibility Agreement • August 26th, 2015
In order for Gastroenterology Associates, LLP to continue providing our patients with quality medical care, we must receive the contracted payment for our services. Ensuring that we are appropriately and promptly paid is the PATIENT’S RESPONSBILITY.
Patient Financial Responsibility AgreementPatient Financial Responsibility Agreement • April 25th, 2019
This letter is to inform you that Hines Family Dentistry may or may not participate with your dental plan. We will submit any claims to your dental plan, but you will be responsible for any remaining balance for all services rendered. It is important for you to understand that your procedure(s) may or may not be reimbursable by your insurance depending on your plan.
Patient Financial Responsibility AgreementPatient Financial Responsibility Agreement • April 5th, 2021
Radiance Pediatrics, PLLC is committed to providing you with the best possible care. In order for us to achieve this goal, we need your assistance and understanding of our financial policy. Please read the following carefully. As it is an agreement that you are responsible for payment, and will pay in a timely manner.
PATIENT FINANCIAL RESPONSIBILITY AGREEMENTPatient Financial Responsibility Agreement • August 19th, 2023
Thank you for choosing Connecticut Colon & Rectal Surgery, LLC as your healthcare provider. The medical services you seek entails a financial responsibility on your part. This responsibility obligates you to ensure payment in full for the services you receive. To assist in understanding that financial responsibility, we ask that you read and sign this form. Feel free to ask if you have any questions regarding your financial responsibility. If someone else (parent, spouse, domestic partner, etc.) is financially responsible for your expenses or carries your insurance, please share this policy with them, as it explains our practices regarding insurance billing, co- payments, and patient billing. By signing below and/or by receiving medical services from Connecticut Colon & Rectal Surgery, LLC you agree:
Patient Financial Responsibility AgreementPatient Financial Responsibility Agreement • July 10th, 2013
The doctors and staff of East Texas Vision Center appreciate the confidence you have shown in choosing them to provide for your eyewear needs. We are committed to providing you with the highest quality vision. Please read and sign this form to acknowledge your understanding of our patient financial policies.
Patient Financial Responsibility AgreementPatient Financial Responsibility Agreement • May 2nd, 2019
In order to avoid unexpected charges, you should reach out to your insurance carrier before you initiate treatment here to familiarize yourself with the limits of your policy, and what it will and will not provide coverage for. We do our best to guide patients through this process, but ultimately it is impossible for us to keep abreast of the requirements and stipulations of the thousands of insurance products on the market. It is an individual patient responsibility to understand the provisions, limits, and requirements of their individual benefit plan(s) and advise us accordingly.
