PATIENT SERVICE AGREEMENTPatient Service Agreement • August 20th, 2021
Welcome to the Mountain View Center for Wellness and Recovery. This document contains important information about our services and business policies. Please read it carefully and note any questions you might have. These can be clarified with your service provider.
Patient Service AgreementPatient Service Agreement • January 25th, 2016
In order to control our costs of billing, we request that charges be paid at the time services are rendered unless we will be billing your insurance. To encourage this, a discount of 10% will be given for cash or check and 5% for credit card payment at the time of service. Charges for cosmetic procedures do not receive a discount and must be paid at the time of the visit.
Patient Service Agreement and Consent FormPatient Service Agreement • May 1st, 2022
Wellness Consulting, Inc and Lori Bergstrom, MFT (“Provider”) are pleased to provide you with personalized support and care. Please read and sign the following agreement; it lists billing, scheduling and cancellation policies and procedures. If you have any questions, please ask for clarification.
BLUESTONE PSYCHOLOGICAL SERVICES, PLLCPatient Service Agreement • February 6th, 2013
PATIENT SERVICE AGREEMENTPatient Service Agreement • April 9th, 2021
PATIENT SERVICE AGREEMENT – CLINICS / OUTPATIENTSPatient Service Agreement • August 24th, 2017
EAP Psychological Services Patient Service AgreementPatient Service Agreement • April 15th, 2024
This document (the Agreement) contains important information about OSU Employee Assistance Program (EAP) psychological services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights regarding the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment and health care operations. HIPAA requires that you are provided with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment, and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that this provider obtains your signature acknowledging that you were provided this information. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can d
PATIENT SERVICE AGREEMENTPatient Service Agreement • November 7th, 2020
Patient Service AgreementPatient Service Agreement • June 25th, 2015
I, , authorize the release of any medical or other information necessary, for CDSG Medical and Wellness, Inc. to process my request for DME supplies and/or equipment, and submit claims to my insurer.
PATIENT SERVICE AGREEMENT (2012)Patient Service Agreement • September 17th, 2020
Patient Service AgreementPatient Service Agreement • February 26th, 2020
PSYCHOTHERAPIST – PATIENT SERVICE AGREEMENTPatient Service Agreement • November 7th, 2020
Welcome to Mark Falango + Associates. This document contains important information about our professional services and business policies. Please read this agreement
ContractPatient Service Agreement • July 6th, 2012
Patient Service Agreement Consent for Services By signing this agreement I give consent to the physicians, medical staff and employees of Utah Vein Specialists to provide health care services to , (Date of Birth).Patient Name Financial Responsibility and Assignment of Benefits I agree that all benefits from insurance companies or any other third party payer will be paid directly to Utah Vein Specialists for services rendered by the health care providers employed by Utah Vein Specialists. I authorize the use of my signature and any records pertaining to my services to all insurance companies, or third party payers to secure payment. I understand that I am financially responsible for all charges whether or not paid by insurance or any other third party payer. I agree to pay all co-payments at the time of service, all deductibles, co-insurance, and all non-covered services regardless of the amount paid by my insurance or any other third party payer. I agree to pay all attorney fees, cou
PATIENT SERVICE AGREEMENTPatient Service Agreement • December 23rd, 2015
ContractPatient Service Agreement • July 23rd, 2007
Heller Psychological Services, P.C. Child/Adolescent/Adult Psychotherapy & Consulting Lindsay Heller, Psy.D., Clinical Psychologist /PSY21400 Phone: 310.384.9300 Email: info@drlindsayheller.com
Account#:Patient Service Agreement • March 24th, 2017
Authorization/Consent to Provide Home Medical (Durable Medical) Equipment: I have been informed of the home medical (durable medical) equipment and supplies available to me and of the selection of providers from which I may choose. I authorize Atos Medical Inc under the direction of the prescribing physician, to provide home medical equipment and supplies as prescribed by my physician.
PATIENT SERVICE AGREEMENT (Versión en Español atrás)Patient Service Agreement • September 20th, 2006
ContractPatient Service Agreement • May 9th, 2014
VAN BUREN COUNTY HOSPITAL PATIENT SERVICE AGREEMENTPatient Service Agreement • February 7th, 2023
Patient Service AgreementPatient Service Agreement • June 26th, 2019
PATIENT SERVICE AGREEMENT – HOSPITALPatient Service Agreement • May 10th, 2016
PATIENT SERVICE AGREEMENTPatient Service Agreement • December 23rd, 2015
Licensed Clinical PsychologistPatient Service Agreement • December 9th, 2023
This document contains important information about my professional services and business policies. It also contains summary information about Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which I am also providing, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions you have about the procedures
PATIENT SERVICE AGREEMENTPatient Service Agreement • September 5th, 2019 • Alabama
This Patient Service Agreement is entered into this day of , 20 (the “effective date”), by and between 10X PhysioTherapy, LLC (“Provider”) and the undersigned patient (“Patient”) for access to the services defined herein (the “Agreement”). Provider and Patient shall hereinafter be referred to as individually the “Party” and collectively as the “Parties.”
PATIENT SERVICE AGREEMENTPatient Service Agreement • October 24th, 2018
Your insurance is a contract between you and your insurance company. We are no a party to that contract. We will pre-certify your coverage at the time of your visit. During pre-certification, every insurance company states, “This is not a guarantee to benefits”.
PATIENT SERVICE AGREEMENTPatient Service Agreement • May 21st, 2008
PATIENT SERVICE AGREEMENTPatient Service Agreement • December 20th, 2019
Authorization/Consent for Care/Service: I authorize VMR Medical under the direction of the prescribing physician, to provide durable medical equipment, supplies and services as prescribed by my physician.
ABILITY PROSTHETICS & ORTHOTICS PATIENT SERVICE AGREEMENTPatient Service Agreement • February 23rd, 2015
Return Patient Service AgreementPatient Service Agreement • April 27th, 2017
Are you ready to dewinterize? Yes No My boat is already dewinterized Dewinterize my boat any time after this date: Other important information we should know?
Patient Service AgreementPatient Service Agreement • January 7th, 2021
At the North Bay Indigenous Hub, the most important job for our team of Health Care Providers is providing quality care to our patients. To do this to the best of our ability, we partner with you, our patient, to create and nurture an atmosphere of respect, comfort, and cultural safety. We therefore ask as a condition of your being rostered with us that you sign this agreement:
KID TALK PATIENT SERVICE AGREEMENTPatient Service Agreement • August 20th, 2021
We are committed to providing consistent quality services to our clients. We expect that same commitment from the families we serve. Our therapists make a professional recommendation as to the frequency and duration of your child’s therapy to ensure you child progresses appropriately. Your child will make the most progress in therapy with consistent attendance. It is also important that you arrive on time so that your child can benefit from a full session. Families that choose to receive services for their child at Kid Talk must adhere to following cancellation policy:
DAVID J. JOHNSON, PH.D – CLINICAL PSYCHOLOGIST 4626 PEACH ST. – LEVEL 2 ERIE, PA. 16509Patient Service Agreement • March 12th, 2013
This document (the Agreement) contains important information about my professional services and business practices and policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protection and patient rights with regard to the use and disclosure of Protected Health Information (PHI). HIPAA requires that I provide you with a Notice of Privacy Practices (The Notice) regarding the use and disclosure of PHI. The Notice, which is attached to this Agreement, explains HIPAA and its application(s) to (your) PHI. The law requires that I obtain your signature acknowledging that I have provided you with this information. Although these documents are long and complex, it is very important that you read them carefully- before our next session. We can discuss any questions you may have about the policies and procedures at that time. When you sign this document, it will also represent an agreement between y
ANGELA F. ARNOLD, MD, LLCPatient Service Agreement • July 19th, 2023
Patient Service AgreementPatient Service Agreement • April 15th, 2011
I, , hereby consent to examination and treatment by Intermountain Heart Center physicians, medical staff, and employees including diagnostic and/or therapeutic procedures ordered by the physician.
PATIENT SERVICE AGREEMENTPatient Service Agreement • February 8th, 2022
This Agreement is entered into by and between Monarch Family Medicine, LLC, Virginia L. Alvord, MD (“Dr. Alvord”) and Date of Birth: (“Patient”).
