PRIVATE PAYMENT AGREEMENT FOR PATIENTS WITH MEDICAREPrivate Payment Agreement • May 14th, 2018
PRIVATE PAYMENT AGREEMENT FOR PATIENTS WITH MEDICAREPrivate Payment Agreement • April 17th, 2017
This agreement is entered into between the undersigned patient, or patient’s legal representative (“patient”), and Thomas P. Gross, M.D. (“physician”) on this day of , 20 .
MEDICARE & MEDICAID PRIVATE PAYMENT AGREEMENTPrivate Payment Agreement • August 31st, 2022
I, (print name of person responsible for payment), by signing this agreement, indicate that I understand that my treatment with Dr. Barroga beginning on
Self/Private Payment AgreementPrivate Payment Agreement • October 13th, 2020
The following agreement outlines the terms of payment between clients who choose not to use insurance coverage and Insightful Minds Counseling, LLC.
Private Payment AgreementPrivate Payment Agreement • September 29th, 2013
Some clients decide not to use their insurance benefits for psychotherapy services. The following agreement outlines the terms of payment between clients who choose not to use insurance coverage and NewPaths, LLC/Sheri Rezak-Irons, LCSW.
