PATIENT PAYMENT AGREEMENTPatient Payment Agreement • January 26th, 2022
This is the remaining balance for dates of service on or before this date which insurance has paid or which is not covered by insurance. Any balance due from charges yet to be paid by insurance will be added to this balance. I understand that this balance is my responsibility and may change if I incur future charges for service rendered after this date.
PATIENT PAYMENT AGREEMENTPatient Payment Agreement • April 28th, 2016
This is to certify the above treatment fees and checked payment option has been explained to me and I fully understand the nature of the treatment recommended. I understand and agree that if my insurance does not pay my insurance claim within 45 days, I am responsible for any balance due. I agree to pay reasonable attorney’s fees, court costs and collection costs incurred by Island View Dental in collection and enforcement of the debt. The above fees will be honored for 6 months or until commencement of treatment, whichever occurs first.
United Dental Services PLLCPatient Payment Agreement • October 29th, 2015
AGREEMENT FOR PAYMENT OF SERVICES:Patient Payment Agreement • February 19th, 2019
We believe that prompt payment for services is part of the contract that exists between doctor and patient. I understand that I am responsible for all charges incurred by me and I understand that I am required to pay them at the time services are rendered.
BAGNELL Dental ClinicPatient Payment Agreement • January 5th, 2017
We are committed to providing you with the best possible dental care. Our fees reflect our professional commitment to excellence. In order to achieve these goals we need your assistance and understanding of our payment policy. We offer the following methods of payment of fees:
PATIENT PAYMENT AGREEMENTPatient Payment Agreement • July 28th, 2024
Payment in full is due at the time of service. We cannot grant exemptions. We offer a 10% discount for accounts paid in full at time of service with cash or check. Insurance, credit and debit card transactions are ineligible for this discount.
Uniquely qualified to help patients break through physical barriers…Patient Payment Agreement • September 17th, 2014
I, , agree that it is my responsibility to understand my health insurance benefits and eligibility for physical therapy services.
Patient Payment AgreementPatient Payment Agreement • April 13th, 2022
Thank you for the opportunity to help you meet your healthcare goals. During our discussion of your treatment recommendation and our Written Financial Policy, the following financial arrangements were made:
Patient Payment AgreementPatient Payment Agreement • July 29th, 2020
Please note: The Benefit Plan/Insurance Contract is between you (the patient) and the Benefit Plan issuer or the Insurance Carrier. As a courtesy to our patients we will bill insurance when we are given the necessary information. It is your responsibility to know what your insurance will pay, and to know if prior- authorization is required, for Physical and Occupational Therapy services with our staff.
Patient Payment AgreementPatient Payment Agreement • February 20th, 2017
CATHERINE A. HA, DMD, PA CAROLINA DENTAL ASSOCIATESPatient Payment Agreement • October 25th, 2009
In this agreement the words “you”, “your” and “yours” mean the Patient/Debtor/Guarantor. 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” or “our” refer to the Doctor.
Patient Payment AgreementPatient Payment Agreement • October 20th, 2020
Wellness Cash-Pay - Patient Payment AgreementPatient Payment Agreement • November 13th, 2020
We offer patients a cash-pay wellness service. This service will not be billed to your insurance and must be paid in full at time of service. No forms or paperwork will be produced now or in the future for insurance billing purposes.
Financial Policies and Patient Payment AgreementPatient Payment Agreement • September 7th, 2022
Alaska Eye Care Centers is committed to providing our patients with the best possible optometric care and minimizing healthcare costs. Our prices are reflective of the usual and customary charges for our area. The following policy statement and financial agreement outlines the patient's and the practice's financial responsibilities concerning payment for services:
MIDTOWN UROLOGY – PATIENT PAYMENT AGREEMENTPatient Payment Agreement • February 6th, 2023
Insurance co-pays are due at the time of service and before you see the doctor. If you are unable to pay your co- pay you will be asked to reschedule your appointment. Due to the fact that Midtown Urology is a specialty practice, higher copays may be indicated (consult your individual insurance policy benefits for clarification).
East Dental Family Dentistry, PLLCPatient Payment Agreement • September 21st, 2022
Thank you for the opportunity to help you meet your oral health goals. Please fill out the following financial arrangement, sign, date, and send back to us:
Dear Patient,Patient Payment Agreement • May 13th, 2016
We will file your charges to your insurance company as a courtesy for you. If they reject your visit, for any reason, you will be held responsible. The balances are ultimately your responsibility. We will try any and all means to work with you to take care of your bill with our office.
JANIS L. ENZENBACHER, MDPatient Payment Agreement • September 18th, 2023
Timothy J. Kerr, DMDPatient Payment Agreement • September 30th, 2009
PATIENT PAYMENT AGREEMENTPatient Payment Agreement • November 29th, 2007
It is our preferred office policy that payment is due at the time of service. However, we understand that occasionally patients may need to make a temporary payment agreement while receiving necessary chiropractic care. Your health is our first concern and we are willing to extend the following payment agreement:
Nina Basti DDS, INC.Patient Payment Agreement • October 30th, 2014
Thank you for the opportunity to help you meet your oral health goals. During our discussion of your treatment recommendation and our Written Financial Policy, the following financial arrangements were made:
PATIENT PAYMENT AGREEMENTPatient Payment Agreement • August 15th, 2024
Ace DentalPatient Payment Agreement • October 7th, 2017
Thank you for the opportunity to help you meet your oral health goals. During our discussion of your treatment recommendation, the following financial arrangements were made:
PATIENT PAYMENT AGREEMENT FOR SELF PAY, DEDUCTIBLE, AND NON-COVERED SERVICESPatient Payment Agreement • March 4th, 2019
Randy Kay DDS Jared Kay DMDPatient Payment Agreement • November 24th, 2009
PATIENT PAYMENT AGREEMENTPatient Payment Agreement • May 3rd, 2018
This is to certify the above treatment fees and checked payment option has been explained to me and I fully understand the nature of the treatment recommended. I understand and agree that if my insurance does not pay my insurance claim within 45 days, I am responsible for any balance due. I agree to pay reasonable attorney’s fees, court costs and collection costs incurred by Island View Dental in collection and enforcement of the debt. The above fees will be honored for 6 months or until commencement of treatment, whichever occurs first.
CONTRACT PERTAINING TO PAYMENT PATIENT DETAILSPatient Payment Agreement • February 25th, 2016
Full Names: Mr/Mrs/Me: I.D. Number: Postal Address: Code: Home Address: City:Code: Employer/Occupation/Work Address: Tel. No. (Home) Tel. No. (Work): Cell. No.: E-mail Address: Marital Status:If you are married, How? COP ANC Home Language: No. of Dependants:
Patient Payment AgreementPatient Payment Agreement • September 8th, 2021
Thank you for the opportunity to help you meet your oral health goals. During our discussion of your treatment recommendation and our Written Financial Policy, the following financial arrangements were made:
