AGREEMENT TO PAY FOR SERVICES if Premium is Not Paid You are not entitled to any services for periods for which the premium has not been paid. If services are received during such period, you agree to pay for the services received.
AGREEMENT TO PAY FOR SERVICES. Associate Company agrees to pay to Service Company the cost, determined as herein provided, of such services as are requested by Associate Company and are provided by Service Company. It is the intent of this Agreement that all disbursements and expenses of the service company for service performed for associate companies are recoverable from such companies , including reasonable compensation for necessary capital as permitted by applicable rules and requirements of FERC under the Act. The methods and procedure for determining the cost of services performed for Associate Company are set forth in Appendix A hereto. Bills will be rendered for each calendar month on or before the twentieth day of the succeeding month and will be payable upon presentation and not later than the last day of that month. Monthly charges may be made in whole or in part for particular expenses on an estimated basis, subject to adjustment. Notwithstanding any other provisions of this Agreement, Service Company shall ensure that all charges billed to Associate Company hereunder shall be reasonable, purposeful and consistent with historical precedent and cost allocations to other System companies.
AGREEMENT TO PAY FOR SERVICES. I understand that I am liable and responsible for any health insurance deductibles and coinsurance portions of my bill. I also understand that I am responsible to pay for all services to be rendered to the patient whether signing as agent or as patient. The undersigned certifies that (s)he has read the forgoing or that it has been read to him/her, and that (s)he understands the same and consents thereto, and that (s)he is the patient or the duly authorized representative or agent of the patient to sign the form and consent thereto. I further understand that my treatment may require more than one occasion or service; therefore, this consent shall carry full force and effect from the date of signature until I am discharged from further treatment. DATE: NAME OF PATIENT (Signature of Patient or Legal Representative) (Signature of Witness) (Relationship, if other than parent) If patient is unable to sign, or is a minor, complete the following: Patient is (a minor years of age) or is unable to sign SEE REVERSE SIDE
AGREEMENT TO PAY FOR SERVICES. Associate Company agrees to pay to Service Company the cost, determined as herein provided, of such services as are requested by Associate Company and are provided by Service Company. It is the intent of this Agreement that the payment for services rendered by the Service Company to the System shall cover all the costs of its doing business (less credits for services to non- System companies and any other miscellaneous income items), including reasonable compensation for necessary capital as permitted by applicable rules and requirements of FERC under the Act. The methods and procedure for determining the cost of services performed for Associate Company are set forth in Appendix A hereto. Bills will be rendered for each calendar month on or before the twentieth day of the succeeding month and will be payable on presentation and not later than the last day of that month. Monthly charges may be made in whole or in part for particular expenses on an estimated basis, subject to adjustment, so that all charges for services during a calendar year will be made on an actual basis. Notwithstanding any other provisions of this Agreement, Service Company shall ensure that all charges billed to Associate Company hereunder shall be reasonable, purposeful and consistent with historical precedent and cost allocations to other System companies.
AGREEMENT TO PAY FOR SERVICES. I acknowledge and accept that no guarantee has been given as to the results these treatments may produce in me. I further acknowledge and accept that any treatment(s) given may not help me and may make my condition worse. For and in consideration of the care and treatment provided to the patient, I promise to pay, or arrange for payment, AT THE TIME OF THIS VISIT all charges due for services rendered to or on behalf of the patient. Payment may be made by cash, check or credit card. Legal action to collect money from insufficient fund checks or stop payment checks; will be at the patient’s expense. In the event your account is turned over to a collection agency, a 35% fee will be added to the balance. Any fees associated with the collection of a past due balance will be the responsibility of the patient.
AGREEMENT TO PAY FOR SERVICES. For and in consideration of the services provided to the patient, I promise to pay the above company for all charges and services rendered to or in behalf of the patient. The above company may secure any credit information that may be necessary. I also understand that I may be insured through a PPO/HMO plan and that it is my responsibility to obtain the proper and necessary referrals from my primary care physician before services are rendered. The above company shall make all reasonable efforts to assure that the insured is covered by the plan, but ultimately I understand that it is my responsibility. DIRECT PAYMENT AUTHORIZATION By way of original or a copy hereof, the undersigned patient hereby directs the applicable personal injury protection or medical payments insurance carrier to make payment directly to the above companies. If payment is made out to the above company they have the authorization to endorse the payment with the patient's signature along with its own. RELEASE OF INFORMATION I hereby authorize the above company to release any information in the course of my treatment to my insurance company or any physician needing this information for treatment.
AGREEMENT TO PAY FOR SERVICES. Financial Agreement. In consideration of the services to be rendered to the patient, I individually promise to pay the patient’s account at the rates established in the hospital’s price list (known as the “Charge Master”) as the same are in effect as of the date the charge is processed for the service provided, which rates are hereby expressly incorporated by reference as the price term of this agreement. Some special items will be priced separately if there is no price listed on the Charge Master.
AGREEMENT TO PAY FOR SERVICES. I understand that I am liable and responsible for any health insurance deductibles and coinsurance portions of my xxxx. I also understand that I am responsible for paying for all services to be rendered to the patient whether signing as agent or as patient The undersigned certifies that (s)he has read the foregoing or that it has been read to him/her, and that (s)he understand the same and consents thereto, and that (s)he is the patient or duly authorized representative or agent of the patient to sign this form and consent thereto. I further understand that my treatment may require more than one occasion of service, therefore; this consent shall carry full force and effect from the date of signature until I am discharged from further outpatient treatment As an outpatient, I understand that treatment may be rendered at AICHC. Its outpatient facility or one of its outpatient satellites. I further understand and acknowledge that an HIV test may be performed upon myself, and in cases of birth, my child/children, without the written consent required under circumstances that a health professional, other health facility employee or emergency first responder (as defined in Act 419 of 1994) sustains a percutaneous mucous membrane, or open wound exposure to my, or In cases of birth, my child/children’s blood or other body fluids. Signature of patient or personal representative Name of patient or personal representative Relationship to the patient (if not self) Date Signature of witness Name of witness Date If patient is unable to sign or is a minor, complete the following; Patient is (a minor years of age or is) unable to sign because Patient’s Name:
AGREEMENT TO PAY FOR SERVICES. I agree to pay all charges for services that I incur. If I use insurance to cover some or all of my counseling at Tender Rock Counseling, I agree to pay any amounts that my insurance carrier does not pay. These may include, but are not limited to, services and charges determined by my insurance carrier to be my responsibility or not covered by my insurance plan. If I incur a charge for a missed or late-canceled group therapy session, I understand that I will be responsible for payment of the agreed-upon fee per session. The responsible party hereby agrees that accounts not paid within thirty (30) days will accrue interest at the rate of 1.5% per month (18% A.P.R.). In the event this account is turned over to an attorney or agency for collection, the responsible party agrees to pay all costs of collection including, but not limited to, court costs and collection fees. My/Our initials here indicate I/we understand there is no diagnosis that will be provided by the Group Facilitator. I/we have read, understand, and agree to the above. Client Signature: Date: Guarantor Signature: (Parent or guarantor if client under 18 years old) Date:
