Patient Responsibility AgreementPatient Responsibility Agreement • October 30th, 2023
Patient Responsibility AgreementPatient Responsibility Agreement • June 5th, 2018
The following is a list of responsibilities required of a patient to participate in the Subcutaneous Immune Globulin (SCIG) home infusion program:
Patient Responsibility AgreementPatient Responsibility Agreement • June 4th, 2024
Patient Responsibility Agreement - Over 18 HIPAA Release and ConsentPatient Responsibility Agreement • April 29th, 2014
Patient Responsibility AgreementPatient Responsibility Agreement • September 20th, 2022
Thank you for choosing our practice for your health care needs. We are committed to building a successful physician- patient relationship with you and your family. Your clear understanding of our patients' code of conduct and financial responsibility is important to our professional relationship. Compliance with our practice policies impacts that relationship. If you have any questions about your responsibilities, our fees or policies please do not hesitate to ask.
Bill of Rights and Disclosure AgreementPatient Responsibility Agreement • November 7th, 2018
• I agree to be on time for my appointment and I understand I may be billed for any appointments missed if I fail to notify the office 48 hours in advance.
Bill of Rights and Disclosure AgreementPatient Responsibility Agreement • December 9th, 2013
• I agree to be on time for my appointment and I understand I may be billed for any appointments missed if I fail to notify the office 48 hours in advance.
Patient Responsibility Agreement Over 18 HIPAA Release and ConsentPatient Responsibility Agreement • October 3rd, 2016
Patient Responsibility Agreement Over 18 HIPAA Release and ConsentPatient Responsibility Agreement • March 7th, 2018
PATIENT RESPONSIBILITY AGREEMENTPatient Responsibility Agreement • July 11th, 2016
This is to inform you that your insurance carrier may not cover procedures or diagnostic tests that your doctors consider necessary for the proper treatment of your medical condition. We agree to file the claims for you and assist in any appeal process necessary.
Patient Responsibility AgreementPatient Responsibility Agreement • October 26th, 2017
Patient Responsibility AgreementPatient Responsibility Agreement • April 8th, 2023
Check We gladly accept your check; if your check is dishonored or returned for any reason we will electronically debit your account for the amount of the check plus a processing fee of 35.00.
Patient Responsibility AgreementPatient Responsibility Agreement • October 6th, 2023
If you have both Medicaid and a commercial insurance, the total cost of your treatment will be covered. If you do not have Medicaid, you will be responsible to pay for the cost of your services. If you are insured with a Health Maintenance Organization (HMO), you will need a referral prior to receiving services. If you fail to obtain a referral, you will be charged the full cost of services.
Patient Responsibility AgreementPatient Responsibility Agreement • July 25th, 2016
Patient Responsibility Agreement Over 18 HIPPA Release and ConsentPatient Responsibility Agreement • November 12th, 2020
Patient Responsibility AgreementPatient Responsibility Agreement • August 7th, 2018
DAVID STEINMAN, MD, PCPatient Responsibility Agreement • March 25th, 2020
Patient Responsibility AgreementPatient Responsibility Agreement • November 19th, 2021
Patient Responsibility AgreementPatient Responsibility Agreement • December 5th, 2018
Patient Responsibility Agreement/Referral WaiverPatient Responsibility Agreement • July 21st, 2016
PATIENT RESPONSIBILITY AGREEMENTPatient Responsibility Agreement • July 23rd, 2020
For all patients, payment of insurance co-pays, deductibles, and services not covered by insurance are to be paid for at the time the service is rendered.
Willow Bend PediatricsPatient Responsibility Agreement • October 26th, 2023
Patient Responsibility AgreementPatient Responsibility Agreement • February 10th, 2016
I, , understand that my insurance company will be billed for applicable out-of-network charges related to services provided to me by CereHealth MSO, LLC (“CereScan”).
ContractPatient Responsibility Agreement • March 11th, 2014
PATIENT RESPONSIBILITY AGREEMENT/PAYMENT OPTIONSPatient Responsibility Agreement • July 18th, 2019
We will be happy to process your Insurance Claim Forms. While this is a courtesy we extend to our patients, ALL charges are the responsibility of the patient. We will do our best to ESTIMATE your portion of payment at the time of service; however, it is the patient’s responsibility to verify eligibility of their plan. The patient must pay any estimated portion AT THE TIME OF SERVICE.
BEAVERCREEK DENTALPatient Responsibility Agreement • June 25th, 2018
We will be happy to process your Insurance Claim Forms. While this is a courtesy we extend to our patients, ALL charges are the responsibility of the patient. We will do our best to ESTIMATE your portion of payment at the time of service; however, it is the patients’ responsibility to verify eligibility of their plan. The patient must pay any estimated portion AT THE TIME OF SERVICE.
Patient Responsibility Agreement Over 18 HIPAA Release and ConsentPatient Responsibility Agreement • December 6th, 2022
PATIENT RESPONSIBILITY AGREEMENTPatient Responsibility Agreement • July 11th, 2016
This is to inform you that your insurance carrier may not cover procedures or diagnostic tests that your doctors consider necessary for the proper treatment of your medical condition. We agree to file the claims for you and assist in any appeal process necessary.
PATIENT RESPONSIBILITY AGREEMENT and INSURANCE POLICYPatient Responsibility Agreement • February 19th, 2019
We would like to take this opportunity to Welcome you to our practice and assure you that we will do our utmost to provide you or your child with the best possible care. The following is a statement of our Financial Policy, which we require that you read, agree to and sign prior to you/your child’s first visit.
Patient Responsibility AgreementPatient Responsibility Agreement • September 7th, 2018
We bill all insurance payers although we may not be contracted with all insurance companies. If we are a network provider for your insurance company, they will pay for our services at the negotiated rate and we will apply the appropriate payments and adjustments to your account. It is your responsibility to pay deductibles, copayments or coinsurances. All out of network charges will be negotiated as discussed per this agreement.
PATIENT RESPONSIBILITY AGREEMENTPatient Responsibility Agreement • September 20th, 2016
Patient Responsibility Agreement Over 18 HIPPA Release and ConsentPatient Responsibility Agreement • July 11th, 2016
PATIENT RESPONSIBILITY AGREEMENTPatient Responsibility Agreement • July 11th, 2016
This is to inform you that your insurance carrier may not cover procedures or diagnostic tests that your doctors consider necessary for the proper treatment of your medical condition. We agree to file the claims for you and assist in any appeal process necessary.
Patient Responsibility AgreementPatient Responsibility Agreement • May 1st, 2024
Patient Responsibility Agreement/Referral WaiverPatient Responsibility Agreement • November 18th, 2003
