FINANCIAL AGREEMENT. In addition to all of Institute of Healthcare, Inc academic standards and policies, I understand that The Institute of Healthcare is not currently recognized with institutional accreditation recognized by the United States Department of Education. Students are not able or eligible to participate in federal financial aid programs in association with the Institute of Healthcare, Inc. With that being said, the applicant will be withdrawn from the course for failure to meet financial obligation. “Prior to signing this enrollment agreement, you must be given a catalog or brochure and a School Performance Fact Sheet, which are encouraged to review prior to signing this agreement. These documents contain important policies and performance data for this institution. This institution is required to have you sign and date the information included in the School Performance Fact Sheet relating to completion rates placement rates, license examination passage rates, and salaries or wages, and the most recent three- year cohort default rate, if applicable, prior to signing this agreement. “As a prospective student, you are encouraged to review this catalog prior to signing an enrollment agreement. You are also encouraged to review the School Performance Fact Sheet, which must be provided to you prior to signing an enrollment agreement.” “I certify that I have received the catalog, School Performance Fact Sheet, and information regarding completion rates, placement rates, license examination passage rates, salary or wage information, and the most recent three-year cohort default rate, if applicable, included in the School Performance Fact sheet, and have signed, initialed, and dated the information provided in the School Performance Fact Sheet.” “I understand that this is a legally binding contract. My signature below certifies that I have read, understood, and agreed to my rights and responsibilities, and that the Institutions cancellation and refund policies have been clearly explained to me.” Applicant Signature Applicant Print Name Date Authorized Employee of Institute of Healthcare, Inc. Signature Print Title Date “NOTICE” “YOU MAY ASSERT AGAINST THE HOLDER OF THE PROMISSORY NOTE YOU SIGNED IN ORDER TO FINANCE THE COST OF THE EDUCATIONAL PROGRAM ALL OF THE CLAIMS AND DEFENSES THAT YOU COULD ASSERT AGAINST THIS INSTITUTION, UP TO THE AMOUNT YOU HAVE ALREADY PAID UNDER THE PROMISSORY NOTE.” TOTAL CHARGES FOR THE CURRENT PERIOD OF ATTENDANCE: $1,595.00 ESTIMATED TOTAL C...
FINANCIAL AGREEMENT. I understand that there is no guarantee of reimbursement or payment from any insurance company or other payer. I understand this Agreement is a contract and that it obligates me to pay all charges for my treatment not paid by my insurer or any other payer source. I understand the Hospital has pre-determined the charges for certain procedures, supplies, and treatments, which these charges are listed in the Hospital’s Chargemaster, and these prices are incorporated by reference into this Contract. I acknowledge it may not be possible to state in advance which specific supplies and services will be part of my treatment. I acknowledge I have the right to receive an estimate of the facility’s average charge for treatment that are frequently performed on in-patient, outpatient, or surgical procedures. If I receive an estimate of charges, I acknowledge that the Hospital is acting in good faith by providing such an estimate. I acknowledge that any estimate is not binding and that the charges I am personally obligated to pay may be more than the estimated charge for my specific treatment. I acknowledge this Contract means I personally have full financial responsibility for, and agree to pay, all charges for the Hospital and of physicians rendering services not otherwise paid by my health insurance or other payer based upon the Hospital’s pre-determined Chargemaster rates. Estimated patient responsibility is due at the time of service or following the medical screening exam. Any remaining charges are due and payable upon receipt of the xxxx. I acknowledge and understand that any refund that I may be owed will first be applied to any outstanding balance, and the remainder will be forwarded to the address on file with the Hospital. If I do not have insurance or I cannot pay my xxxx, I may qualify for financial assistance. I understand that I may be required to submit documentation to determine my eligibility for financial assistance. I understand the hospital may request and use data from third parties such as credit reporting agencies in order to verify demographic data or evaluate financial options. If payment is not made within 180 days after receipt of the xxxx, a delinquent charge or interest at the maximum legal rate may be added. I agree to pay all legal expenses necessary for the collection of any debt or any action on this Contract. I hereby acknowledge and agree that the Hospital has not made any implied representations about the charges I am personally obli...
FINANCIAL AGREEMENT. I will give a nonrefundable deposit of $100 at the first team meeting to solidify my commitment to this trip. • I understand that I am financially responsible for the full trip cost and agree to raise funds or self-fund as necessary to meet this goal. • Once airline tickets have been purchased, I am responsible for 100 percent of the ticket price, even if I have to withdraw from the global(x) trip. • I agree to meet fundraising deadlines as determined by global(x), and I understand that failure to meet one of the deadlines may result in being unable to go on the trip. • In the event I am unable to participate in the global(x) trip, I understand that all funds raised are nonrefundable and nontransferable to a future global(x) trip. • I understand that any funds raised over the required amount for my trip are nonrefundable and will be used to cover overall trip costs and/or international projects as determined by the global(x) staff. Initial here: TALENT RELEASE I, hereby permit global(x) and The 410 Bridge, Inc. (The 410 Bridge) to use any audio, video, written, or pictorial footage of myself taken while on this global(x) trip for future promotions of global(x) and the 410 Bridge. I understand that neither global(x) nor The 410 Bridge will use any of this footage for any purposes or organizations outside of marketing for global(x) and The 410 Bridge, nor will they sell or release this material to any outside party. Initial here: SIGNATURE PAGE I have read and agree to the following: global(x) Code of Conduct, Team Agreement, Financial Agreement, and Talent Release. Signed: Date: Name (please print): MEDICAL AND LIABILITY RELEASE global(x), operated by North Point Ministries, Inc., under the supervision of the staff and volunteers of North Point Community Church, Buckhead Church, Browns Bridge Church, Woodstock City Church, Gwinnett Church, and/or Decatur City Church, along with The 410 Bridge, Inc. (The 410 Bridge) require the completion and acceptance of a medical and liability release prior to participation in a global(x)/410 Bridge trip. Trip Dates: Country:
FINANCIAL AGREEMENT. I understand that all charges are due at the time of service. I agree to pay Xxxxxxxxx Prompt Care for all charges for healthcare services and professional services provided to me by physicians and other healthcare professionals. Acceptable forms of payment include Cash, Visa, MasterCard, Discover, and American Express. If I am a non-insured patient, I agree to pay for my visit in full at the time of service. If Effingham Prompt Care is a participating provider with my insurance company, I understand that my co-pay, coinsurance, deductible, and/or any outstanding balances are due at the time of service. I understand that my insurance policy is a contract between myself and my insurance company. In order for Effingham Prompt Care to file claims and accept payments from my insurance carrier, I understand that I must present current insurance information at each visit and that Effingham Prompt Care will need to verify my health insurance coverage. In the event that Xxxxxxxxx Prompt Care is not able to verify my insurance eligibility and benefits before my visit, I agree to pay for my visit in full at the time of service. A refund will be issued if my insurance pays for the visit. I also understand that I am financially responsible for any services not covered by my insurance company. When my spouse or a financial guarantor signs this agreement, the spouse or the financial guarantor shall be jointly and individual liable with me. Should my account(s) be referred to an attorney or a collection agency for the collection, the undersigned shall pay the actual attorney’s fees (including costs) and collections expenses incurred in addition to the other amounts due. Unpaid accounts referred to outside agencies for collection shall bear interest at the current rate per year from the date of referral. Insurance Authorization and Release: I request the payment of authorized benefits, including Medicare, and any other government sponsored program, private insurance, and any other health plans to be made to Effingham Prompt Care for any services furnished by that provider. To the extent necessary to coordinate my health care or determine liability for payment and to obtain reimbursement for services rendered, I authorize Effingham Prompt Care to disclose portions of or all of my records, including my medical records to any person or corporation which is or may be liable for all or any portion of Effingham Prompt Care charges, including but not limited to insurance compani...
FINANCIAL AGREEMENT. The following is a description of financial responsibilities of the Individual Activity Applicant and the co-provider(s): Individual Activity Applicant Representative, Name and official title: ___________________________________________________________________________________ Signature of Individual Activity Applicant Representative: _____________________________________ Name of Individual Activity Applicant organization: ___________________________________________________________________________________ Co-Provider Representative Name and official title: __________________ _________________ Signature of Co-Provider Representative: _________________________________________________ Co-Provider Name/Agency: ___________________ _____ _______ Address: ___________________________________________________________________________ Phone: __ Email address________________________________________
FINANCIAL AGREEMENT. By signing and submitting this form, I agree to the following payment and cancellation policies:
FINANCIAL AGREEMENT. For the services to be rendered, I agree to accept full financial responsibility for the patient’s account in accordance with the regular rates and terms of Stanford Medicine Partners. This includes financial responsibility for all deductibles and co-payments that may be required by the patient’s insurance or health plan. This also includes services or supplies not covered by the patient’s health insurance plan and/or Medicare. Should the patient’s account(s) be referred to an attorney or a collection agency for collection, I further agree to pay actual attorneys’ fees and lawsuit-related expenses incurred in addition to other amounts due. When the services are to be billed to insurance, a health plan or another payment source, paragraphs 6 (Contracted Health Plan Patients and Other Sources) and 7 (Assignment of insurance Benefits) will also apply.
FINANCIAL AGREEMENT. I will give a nonrefundable deposit of $100 at the first team meeting to solidify my commitment to this trip. • I understand that I am financially responsible for the full trip cost and agree to raise funds or self-fund as necessary to meet this goal. • Once airline tickets have been purchased, I am responsible for 100 percent of the ticket price, even if I have to withdraw from the global(x) trip. • I agree to meet fundraising deadlines as determined by global(x), and I understand that failure to meet one of the deadlines may result in being unable to go on the trip. • In the event I am unable to participate in the global(x) trip, I understand that all funds raised are nonrefundable and nontransferable to a future global(x) trip. • I understand that any funds raised over the required amount for my trip are nonrefundable and will be used to cover overall trip costs and/or international projects as determined by the global(x) staff. Initial here: I, hereby permit global(x) and North Point Ministries Inc. (NPMI) to use any audio, video, written, or pictorial footage of myself taken while on this global(x) trip for future promotions of global(x) and NPMI. I understand that neither global(x) nor NPMI will use any of this footage for any purposes or organizations outside of marketing for global(x) and NPMI, nor will they sell or release this material to any outside party. Initial here: I have read and agree to the following: global(x) Code of Conduct, Team Agreement, Financial Agreement, and Talent Release.
FINANCIAL AGREEMENT. 1. I hereby agree to pay tuition and standard fees according to FACTS Tuition guidelines and the Tuition and Fees Sheet.
FINANCIAL AGREEMENT. Supplies and Services Included in the Facilities Basic Services Rate The home will provide:
