PATIENT FINANCIAL RESPONSIBILITY, ASSIGNMENT AND RELEASE AGREEMENTPatient Financial Responsibility Agreement • August 4th, 2021
Dental treatment is an excellent investment in you and your family’s health and wellbeing. We recognize that long range economy is of prime concern as well. The following rights and responsibilities are outlined below to aid in understanding our future dental relationship.
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, ASSIGNMENT OF BENEFITS, AND AUTHORIZED REPRESENTATIVE AGREEMENTPatient Financial Responsibility Agreement • August 16th, 2022
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, ASSIGNMENT AND RELEASE AGREEMENTPatient Financial Responsibility Agreement • February 20th, 2019
Dental treatment is an excellent investment in you and your family’s health and wellbeing. We recognize that long range economy is of prime concern as well. The following rights and responsibilities are outlined below to aid in understanding our future dental relationship.
Thank you for choosing North Valley Women’s Care (NVWC) as your healthcare provider!Patient Financial Responsibility Agreement • September 15th, 2022
The medical services you seek here imply an obligation on your part to ensure payment in full is made for the service you receive. This Patient Financial Responsibility Agreement will assist you in understanding that financial responsibility.
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.
PATIENT INFORMATION REGARDING PROFESSIONAL FEESPatient Financial Responsibility Agreement • December 26th, 2022
The purpose of this agreement is to clarify your financial responsibilities and allow us to focus on what is most important to all of us–helping you.
Dr. John P. Krueger, D.D.S.Patient Financial Responsibility Agreement • January 5th, 2006
NEUROFEEDBACK PROGRAM PATIENT FINANCIAL RESPONSIBILITY AGREEMENTPatient Financial Responsibility Agreement • November 5th, 2019
Thank you for choosing Neurological Specialists, P.C. as your healthcare provider. The Neurofeedback Program (“Services”) you seek imply a financial responsibility on your part. This responsibility obligates you to ensure payment in full for the Services that you receive. To assist in understanding that financial responsibility, we ask that you read and sign this form. By signing below and/or by receiving medical Services from Neurological Specialists, P.C. (“Neurological Specialists”), you agree to the following:
Ph: 214-216-6564 Fax: 214-385-2574 Patient Financial Responsibility AgreementPatient Financial Responsibility Agreement • June 17th, 2023
I, ______________________________________________________, understand and agree to the following financial responsibilities associated with the medical services provided by Texas Gastroenterology Center PLLC (Dr Muhammad Osman Arif) and/or Texas Arthritis and Rheumatology PLLC (Dr Zainab Shahnawaz).
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 • March 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 • January 7th, 2022
Your signature below forms a binding agreement between, on the one hand, Allergy Asthma Medical Associates, LTD. dba Relief Allergy & Sinus Institute (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 27th, 2020
ContractPatient Financial Responsibility Agreement • August 26th, 2014
PATIENT FINANCIAL RESPONSIBILITY AGREEMENTPatient Financial Responsibility Agreement • December 7th, 2023
Insurance Claims/Payment: As a courtesy, Reis Pediatrics will file your insurance claims for you; however, in the event that your insurance company denies payment for any reason or has not paid within 90 days, the parent(s) and/or guarantor will be responsible for any balance due. It is also the parent(s) and/or guarantor’s responsibility to provide current insurance information, including the insurance subscriber number and mailing address, and to follow up on any benefit questions with the insurance carrier. You are responsible for informing Reis Pediatrics of changes in insurance coverage within 30 days from the date of service, you may be responsible for any charges incurred due to delay in timely submission of charges. We must emphasize that we are a medical care provider; our relationship is with the patient and not the insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the servic
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 • March 26th, 2014
Thank you for choosing San Juan Basin Health as your healthcare provider. We are committed to providing you with the highest quality care. We ask that you read and sign this form to acknowledge your understanding of our patient financial policies.
Patient Financial ResponsibilityPatient Financial Responsibility Agreement • February 20th, 2017
Payment agreement is due at the time of service. We accept cash, personal check and all major credit cards. We will be happy to file all insurance claims for services rendered. Estimated portions unpaid by insurance will be due at the time of service.
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.
Northwest NeuroSpecialists, PLLC Patient Financial Responsibility AgreementPatient Financial Responsibility Agreement • November 24th, 2020
Each time you come to see your doctor, we will ask to see your personal identification and proof of insurance so that we can properly bill your insurance company(ies) and charge you the correct amount.
Patient’s Financial Responsibility Agreement (As of June 13, 2011)Patient Financial Responsibility Agreement • November 19th, 2020
PATIENT FINANCIAL RESPONSIBILITY AGREEMENTPatient Financial Responsibility Agreement • April 20th, 2009
Thank you for allowing Bigfork Physical Therapy & Sports Rehabilitation, Inc. to assist you with your rehabilitation. In the interest of good health care practices, it is desirable to establish a credit policy to avoid misunderstandings. Our primary responsibility is to help our patients experience good health and we wish to spend our time and energy toward that end. Our goal is to make the financial aspect of your recovery as stress‐free as possible.
Patient Financial Responsibility AgreementPatient Financial Responsibility Agreement • August 3rd, 2020
It is in your best interest, as a patient, to know and understand your insurance plan benefits and your responsibility for any deductibles, co-insurance, or co-payment amounts prior to any visit. Not all services are covered in all insurance contracts. In addition, you should be sure that your physician is listed as a participating provider by your insurance company. If your insurance plan does not cover a service or procedure, you are responsible for payment of these charges.
KRISTE BABBITT, MD, PLLCPatient Financial Responsibility Agreement • November 1st, 2017
The purpose of this agreement is to clarify your financial responsibilities and allow us to focus on what is most important to all of us—helping you.
Patient Financial Responsibility Agreement for Synvisc OnePatient Financial Responsibility Agreement • February 29th, 2016
Prior to receiving a Synvisc One injection you will need to contact your insurance carrier to determine if (1) Synvisc One is a covered benefit, and (2) if pre- authorization is required.
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 FOR INJECTAFER INFUSIONSPatient Financial Responsibility Agreement • September 11th, 2015
Northwest Gastroenterology’s Patient Care Agreement outlines patient financial responsibilities, including responsibility for the financial costs of INJECTAFER infusion. You should have already received a copy of the Patient Care Agreement to review and sign. The Patient Care Agreement is online at www.nwgastro.com/patient-information/financial-policy. As noted in the Patient Care Agreement, 24-hour notice to cancel/reschedule an infusion is required to avoid a $25 fee.
Patient Financial Responsibility Agreement Patient Name: ____________________________DOB:________________________Patient Financial Responsibility Agreement • March 14th, 2017
Thank you for choosing San Juan Basin Public Health as your healthcare provider. We are committed to providing you with the highest quality care. 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 • 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 • February 20th, 2018
As a patient, it is in your best interest to know and understand your insurance plan benefits and your responsibility for any deductibles, co-insurance, or co-payment amounts prior to any visit. Not all services are covered in all insurance contracts. In addition, you should be sure that your physician is listed as a participating provider by your insurance company. If your insurance plan does not cover a service or procedure, you are 100% responsible for payment of these charges.
